Every finding on record at St Antoine Residence

Based on clinical record review and staff interview, the facility failed to ensure that the attending practitioner was immediately notified of a significant change in a resident's physical and clinical status for 1 of 1 resident reviewed with a change in condition, Resident ID #1. Specifically, nursing staff failed to notify the provider of Resident #1's acute decline in functional mobility (digressing from a 2-assist walker transfer to requiring the use of a mechanical lift for transfers) and multiple clinical manifestations of unmanaged pain (wincing, grimacing, heavy lateral leaning, and pointing to his/her right lower extremity) following consecutive falls on 6/16/2026 and 6/17/2026.Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 6/24/2026 alleges in part, that Resident ID #1 fell on 6/17/2026 and was not provided with any follow up care for 5 days. On day 5, x-rays were obtained and they indicated a fracture. The complaint further alleges the resident was grimacing in pain prior to receiving the x-rays. Record review revealed Resident ID #1 was admitted to the facility in June of 2026 with diagnoses including, but not limited to, dementia and history of falling.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that a Brief Interview for Mental Status (BIMS) was not attempted because the resident was rarely/never understood. The MDS revealed that the resident required assistance with all activities of daily living (ADLs).Review of a physical transfer assessment dated [DATE] established that the resident's baseline transfer status was a 2-person assist with the use of a rolling walker.Review of the progress notes revealed the following entries:-6/16/2026 the resident was intercepted wandering into another resident's room, turned, and slid onto the floor.-6/17/2026 the resident was found lying on the floor in the common area. The provider was notified of the fall, and laboratory tests were ordered.Record review revealed that no diagnostic imaging was ordered on 6/17/2026, per the physician's request. Review of the Physical Therapy Treatment Encounter Note revealed the following:-6/17/2026 Physical Therapy (PT) documented, prior to the resident's fall later that day; there were no signs or symptoms of pain via verbal or non-verbal communication.-6/18/2026 the Nursing Assistant (NA) and floor nurse reported the resident had difficulty with mobility and getting out of bed. During the PT assessment, the resident was unable to take steps forward or pivot. The resident's family representative reported to staff that the resident may be having pain and is unable to communicate that. PT documented that the resident appeared to be uncomfortable.Record review failed to reveal evidence that nursing staff notified the provider of the resident's inability to ambulate or concerns relative to pain.-6/19/2026 PT documentation revealed the resident exhibited visible facial grimacing during right lower extremity (RLE) movement and pointed directly to his/her right knee. PT downgraded the resident's transfer status from a 2-person walker transfer to a mechanical lift. PT staff documented that they provided education to the floor nurses and NAs regarding the resident's repeated facial grimacing during RLE manipulation. The representative again reported that the resident is not himself/herself today. Record review failed to reveal evidence that nursing staff notified the provider of the transfer status downgrade or the localized non-verbal pain cues.-6/21/2026 PT notes revealed the resident presented as very rigid, stood with a heavy left lateral lean, and refused to bear weight.Review of a nursing progress note dated 6/21/2026 (four days after the fall on 6/17/2026 and three days after his/her acute mobility decline) revealed that the Nurse Practitioner (NP) was updated regarding the resident's increased pain and concerns with mobility. The NP subsequently ordered an X-ray of the hip and lumbar spine.Record review revealed the ordered X-ray was not obtained until 6/22/2026.PT documentation on 6/22/2026 noted the resident was in escalating pain, wincing/grimacing and pointing to the RLE and pelvic area.Review of the Medication Administration Record (MAR) for June 2026 revealed the resident had an active, scheduled order for Tylenol Oral Tablet 325 milligram (mg) give 2 tablets by mouth two times a day for osteoarthritis pain, which was documented as administered as ordered. Despite receiving this scheduled baseline medication for pain, the record showed that the resident was experiencing breakthrough orthopedic pain following the fall. For this breakthrough pain, the resident only received two as-needed doses of Tylenol 650 mg throughout the entire post-fall period (one dose on 6/18 for a recorded pain score of 3/10, and one dose on 6/22 for a recorded pain score of 5/10).Record review failed to reveal evidence of provider notification regarding the failure of the current pain regimen to control the residents' acute symptoms.The X-ray completed on 6/22/2026 revealed a right hip fracture. Review of hospital documentation dated 6/23/2026 revealed the resident was transferred and admitted for orthopedic surgery. The hospital physician noted: Resident had a fall on 6/17/2026 . delayed imaging shows neck of femur fracture (a break in the upper part of the right thigh bone just below the hip joint).During a surveyor interview on 7/9/2026 at 12:36 PM, with Licensed Practical Nurse, Staff A, she revealed that the resident was able to answer simple yes or no questions. She further revealed that the resident would verbally deny pain but would be grimacing while denying it.During a surveyor interview on 7/9/2026 at 12:45 PM with the Unit Manager, he revealed that he could not remember if the acute pain or a change in mobility status was ever reported to the provider. He was unable to provide any documentation or evidence that the provider was notified of the change in the resident's status.During a surveyor interview with the Director of Nursing Services on 7/9/2026 at 12:52 PM, she was unable to provide evidence that the provider was notified of Resident #1's significant change in condition between 6/18/2026 and 6/21/2026.The facility failed to recognize Resident ID #1's loss of baseline ability to step or pivot, repeated nonverbal signs of pain during limb movement, and new dependence on a mechanical lift as a significant change in physical status requiring immediate provider notification. As a result, the resident remained with an unstable fractured hip for four days without timely medical evaluation or effective pain management, resulting in actual physical harm.

Based on clinical record review and staff interview, the facility failed to maintain medical records for each resident that are complete and accurately documented, in accordance with accepted professional standards of practice for 1 of 1 resident reviewed for transfer status, Resident ID #3.Findings are as follows:Record review revealed Resident ID #3 was admitted to the facility in January of 2026 with diagnoses including, but not limited to, muscle weakness, and abnormalities of gait and mobility.Record review revealed an order dated 5/13/2026 that the resident required a stand aid (a mechanical lift utilized to assist with standing) with a staff assist of one to transfer.Record review of a care plan with a focus area of Selfcare deficit related to change of condition and decline in function and cognition, had an intervention initiated on 5/14/2026 to Transfer with stand aid and 1 staff assist.Record review of a care plan with a focus area of .is at risk for falls [related to] impaired mobility, impaired cognition. had an intervention dated 4/15/2026 to Transfer stand aid (manual) assist x 1.During a surveyor observation on 6/5/2026 at approximately 10:00 AM revealed a white board on the resident's wall which indicated that the resident required a stand pivot with the assist of one staff member for transfers.During a surveyor interview with Physical Therapy Assistant, Staff A, he revealed that the resident is safe to transfer using the stand pivot method with the assist of one staff member. During a surveyor interview with Physical Therapist, Staff B, she revealed that the resident's transfer status is the stand and pivot method with the assist of one staff member.During a surveyor interview with the Assistant Director of Nursing, she revealed that she would expect the resident's care plan and order to match the resident's requirements for transfer status. She further acknowledged that the resident's order and care plans failed to be updated, when the resident's transfer status changed to the stand and pivot method with the assist of one staff member.

Based on clinical record review and staff interview, the facility failed to establish an Infection Prevention and Control Program (IPCP) that includes, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic for 5 of 6 residents reviewed for antibiotic use, Resident ID #s 5, 13, 16, 89, and 165.Findings are as follows:According to the Centers for Disease Control and Prevention (CDC) document titled, The Core Elements of Antibiotic Stewardship for Nursing Homes states in part, Perform antibiotic 'time outs.' .Nursing homes should have a process in place for a review of antibiotics by the clinical team two to three days after antibiotics are initiated to answer these key questions:Does this resident have a bacterial infection that will respond to antibiotics?If so, is the resident on the most appropriate antibiotic(s), dose, and route of administration?Can the spectrum of the antibiotic be narrowed or the duration of therapy shortened (i.e., de-escalation)?Would the resident benefit from additional infectious disease/antibiotic expertise to ensure optimal treatment of the suspected or confirmed infection . 1. Record review revealed that Resident ID #5 was admitted to the facility in August of 2025 with a diagnosis including, but not limited to, dementia. Record review revealed a physician's order for Doxycycline (an antibiotic) 100 milligrams (mg) twice daily for 10 days, from 12/28/2025 through 1/8/2026.Additional record review failed to reveal evidence that an antibiotic time out or a review at day three was conducted.2. Record review revealed that Resident ID #13 was admitted to the facility in March of 2023 with a diagnosis including, but not limited to, diverticulitis of the large intestine (inflammation or infection of irregular bulging pouches in the intestines).Record review revealed a physician's order for Doxycycline 100 mg twice daily for seven days, from 12/28/2025 through 1/4/2026. Additional record review failed to reveal evidence that an antibiotic time out or a review at day three was conducted.3. Record review revealed that Resident ID #16 was admitted to the facility in January of 2024 with a diagnosis including, but not limited to, pneumonia. Record review revealed a physician's order for Cefpodoxime Proxetil (an antibiotic) 200 mg twice daily for seven days, from 1/24/2026 through 1/31/2026. Additional record review failed to reveal evidence that an antibiotic time out or a review at day three was conducted.4. Record review revealed that Resident ID #89 was admitted to the facility in May of 2025 with a diagnosis including, but not limited to, dementia.Record review revealed a physician's order for Clindamycin HCL (an antibiotic) 300 mg three times a day for 10 days, from 1/20/2026 through 1/30/2026. Additional record review failed to reveal evidence that an antibiotic time out or a review at day three was conducted.5. Record review revealed that Resident ID #165 was admitted to the facility in April of 2018 with a diagnosis including, but not limited to, sepsis.Record review revealed a physician's order for Meropenem intravenous solution reconstituted (an antibiotic) 500 mg every 12 hours for six days, from 1/13/2026 through 1/19/2026. Additional record review failed to reveal evidence that an antibiotic time out or a review at day three was conducted.During a surveyor interview on 1/29/2026 at 11:41 AM with the Infection Preventionist, she indicated that antibiotics are discussed verbally at staff meetings however antibiotic timeouts or reviews are not documented unless a physician's order is in place.During a surveyor interview with the Director of Nursing Services on 1/29/2026 immediately following the above interview, she could not provide evidence that antibiotic timeouts or reviews were completed.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that a resident received adequate assistive devices and failed to communicate changes in recommended assistive devices to caregivers to prevent accidents, for 1 of 2 residents reviewed who utilized a stand aid (a device used to assist individuals in transitioning from a sitting to a standing position and transferring from surface to surface) for transfers, Resident ID #165.Findings are as follows:A. Record review of a facility policy titled Falls Prevention & Management last revised 10/2022 states in part, .It is the policy of [the facility] that the facility will ensure that each resident receive adequate supervision and assistive devices to prevent accidents.Record review of a procedure titled Guidelines on Tasks to Complete After a Fall states in part, .submit a rehab screen if the resident is not on Hospice services.Record review revealed Resident ID #165 was admitted to the facility in April of 2018 with diagnoses including, but not limited to, hemiplegia (severe weakness or total paralysis of one entire side of the body) and hemiparesis (the inability to move one side of the body) following unspecified cerebrovascular disease (a stroke), partial traumatic amputation of left foot, and vascular dementia.Review of an Annual Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. Further review revealed that the resident was non-ambulatory and dependent on staff for all transfers.Record review of the resident's progress notes revealed the following entries: - 10/17/2025 - The resident lost balance in stand aid. The Nursing Assistant (NA) was with resident using stand aid when resident slid to the floor during the transfer. - 10/31/2025 - While being assisted by a NA the resident fell backwards from the stand aid. - 11/1/2025 - While using the stand aid, the resident was noted to be non-compliant with instructions on proper use of stand aid. - 12/29/2025 - While receiving care in his/her room, the resident was lowered to the floor by two NA's during a transfer using the stand aid. The resident was noted to be non-compliant with directions when using stand aid and a high risk for falling during transfers. - 12/30/2025- The resident was lowered to the floor by staff while in the main shower room. Staff reported that his/her knees were buckling. A referral for physical rehab was made.During a surveyor interview on 1/29/2026 at 9:18 AM with Unit Manager, Registered Nurse, Staff A, she revealed that following a fall it is standard to submit a rehab screen as part of fall guidelines and any changes in a resident's status are communicated with the interdisciplinary team. She further indicated that all screens were scanned into the residents Electronic Medical Record and could be referenced there.Record review failed to reveal evidence that rehab screens were submitted after the resident's falls on 10/31/2025, 11/1/2025, 12/29/2025, and 12/30/2025 per the facility's fall procedure.During a surveyor interview on 1/29/2026 at 9:43 AM with the Director of Rehabilitation, she was unable to provide evidence rehab screens were completed following the above-mentioned falls as indicated by the fall guideline policy. She further revealed that she was unaware that the resident had sustained falls from the stand aid, that the resident was noted to be non-compliant with instructions during use of the stand aid, and that the resident had experienced knee buckling during transfers using the device.B. Record review of a document titled Assignment #1 provided on 1/29/2026, revealed that the resident required assistance of 1-2 staff persons with use of a stand aid for all transfers.Record review of a care plan for falls last revised on 12/30/2025, revealed to utilize a stand aid for transfers.Record review of a progress note dated 1/13/2026, revealed that the residents returned to the facility following a hospitalization for change in medical status. The resident was evaluated by rehab, and a recommendation was made to use a Hoyer lift (a hydraulic-powered device that holds the patient in a hammock-type sling to lift them completely up and transfer them to a new surface) for all transfers.During a surveyor interview on 1/29/2026 at 9:18 AM with Unit Manager, Registered Nurse, Staff A, she revealed that the resident's transfer status and assistive device needed for transfers are communicated to the NAs via the assignment sheet and white boards located in the resident's rooms. She further indicated that the residents care plans are revised to reflect current transfer status, changes, and interventions following a fall.During a surveyor interview on 1/29/2026 at 9:43 AM with the Director of Rehabilitation, she revealed that it was recommended by the rehab department on 1/13/2026 that the staff utilize a mechanical full body Hoyer lift and 2 staff members for transfers due to the resident's functional decline. She further indicated that this had been communicated in writing to nursing and that the resident's whiteboard had been updated. Record review of a document titled Transfer Status Form dated 1/13/2026, signed by the Occupational and Physical Therapist, revealed that the resident required a full body Hoyer lift with assistance from 2 staff persons for transfers.Record review failed to reveal evidence that the residents care plan had been revised. Additional record review failed to reveal evidence the Assignment sheet, used to communicate the residents functional status and assistive device needed for transfers to NAs, had been revised to reflect the change in residents status on 1/13/2026.During a surveyor interview on 1/30/2026 at 9:00 AM with Staff A, she revealed that the residents change of status had been provided to another nurse on 1/13/2026. She acknowledged that the residents transfer status had not been updated on the NAs assignment sheet. She further acknowledged that the residents care plan had not been revised to reflect the 1/13/2026 recommendation to use a mechanical Hoyer lift.During a surveyor interview on 1/30/2026 at 9:49 AM with the Director of Nursing Services, she revealed that it is her expectation that rehab screens would have been provided to the rehab department following each fall or a change in functional status, per the fall guidelines and policy. Additionally, she acknowledged that the facility failed to clearly communicate the resident's status with NAs and should have to prevent risks of accidents from occurring during transfers.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 3 residents reviewed for oxygen use, Resident ID #76. Findings are as follows:According to Lippincott Nursing Procedure Ninth Edition 2023, page 621, states in part, .Verify the practitioner's order for the oxygen therapy, because oxygen is considered a medication or therapy and should be prescribed .Review of an undated facility policy titled, Oxygen Therapy Procedure states in part, .A physician's order is required.make sure that the oxygen flow rate is set at the amount specified.Documentation: date and time of oxygen administration.rate of flow.Record review revealed the resident was admitted to the facility in June of 2022 and readmitted in January of 2026 with diagnoses including, but not limited to, pneumonia and acute respiratory failure (a life-threatening condition where the lungs suddenly can't effectively exchange oxygen and carbon dioxide, leading to dangerously low blood oxygen or high carbon dioxide levels).Review of a physician's order dated 12/13/2025 revealed to administer oxygen at 2 liters (L) as needed (prn).Surveyor observations revealed the resident was receiving 3L of oxygen instead of 2L, as ordered on the following dates and times:- 1/27/2026 at 10:27 AM and at 12:24 PM- 1/28/2026 at 11:20 AM- 1/29/2026 at 10:20 AMDuring a surveyor observation and interview conducted on 1/29/2026 at 10:39 AM in the presence of Registered Nurse Staff B, she stated that the resident was receiving oxygen at 3L per minute and that there was an order for 3L per minute. Upon the surveyor's request, Staff B reviewed the resident's electronic medical record and subsequently acknowledged that the physician's order was for oxygen at 2L per minute, not 3L per minute as previously stated. During a surveyor interview on 1/29/2026 at 10:49 AM with the Unit Manager, Staff C, she acknowledged the resident's oxygen order indicated 2L and not 3L, as observed. During an additional surveyor observation on 1/29/2026 at 11:30 AM, the resident was observed continuing to receive 3L of oxygen instead of 2L, as ordered. This observation occurred after the surveyor had previously notified the facility that the resident was receiving oxygen at an incorrect flow rate. During a surveyor interview on 1/29/2026 at 1:38 PM with the Director of Nursing Services, she indicated that she would have expected the resident to be receive 2L of oxygen, as ordered.

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed with a pre-cancerous lesion to the right temple, Resident ID #1.Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 9/8/2025 alleges that the resident was transferred to an acute care hospital from the facility to be evaluated for a chronic malignant (cancerous) wound on his/her right scalp which was found to have maggots (worm-like creatures that feed on decaying organic matter) in it. Additionally, the report indicated that the resident receives daily wound care to the wound, however, s/he does not allow the staff to clean it.Record review revealed the resident was admitted to the facility in September of 2022 with a diagnosis, including but not limited to, dementia.Record review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 0 out of 15, indicating severe cognitive impairment. Record review of a document titled Continuity of care consultation and referral form dated 12/13/2024 revealed that the resident had a dermatology appointment where a total of 11 pre-cancerous lesions were found on his/her scalp including the right temple. Additionally, the consultation form revealed that a follow-up was scheduled to recheck the lesion on the right temple in a month. Record review of a Continuity of care consultation and referral form dated 1/27/2025 revealed that the resident had a follow-up dermatology appointment where s/he was evaluated for a pre-cancerous lesion on his/her right temple. Additionally, the consultation form revealed an order for Aquaphor (an ointment) to be applied to the lesion twice daily for 14 days.Record review of the January and February 2025 Medication Administration Records revealed the Aquaphor was applied as ordered for the 14 days. Record review of an undated facility policy titled Skin Integrity Management states in part . Skin checks are completed and documented by a nurse weekly. Any wound identified is fully assessed, documented in the EMR [Electronic Medical Record] and a treatment order is obtained by the NP [Nurse Practitioner], MD [Medical Doctor] if warranted .Record review of the nursing notes revealed the following:2/6/2025- the dermatology office called the facility and indicated that the resident required a MOHS procedure (Mohs micrographic surgery- a surgical procedure that is completed to treat skin cancer) as the biopsy results indicated squamous cell carcinoma. The MOHS procedure was scheduled for 2/25/2025.2/24/2025- the family member cancelled the MOHS appointment and indicated that s/he no longer wanted the resident going to dermatology appointments.6/26/2025- The facility spoke with the family member, and s/he agreed to allow wound care to assess and treat the wound and s/he felt that the resident would not tolerate going out to the dermatologist for the MOHS procedure.6/28/2025- The facility spoke with family member again, regarding the lesion on right temple, s/he would like wound care to look at it and see if it can be treated in house. S/he does not feel that the resident would tolerate going to dermatology for the MOHS procedure. At this time an order for ointment and Primapore (a non-adherent dressing) to cover area as s/he is picking at it. Record review failed to reveal evidence that the facility monitored or assessed the lesion/wound to the right temple from 2/10/2025 until 6/28/2025 when it was documented that the resident was picking at the lesion/wound. Record review revealed the following physician orders:6/28/2025- an antibiotic ointment to be applied to the open area on the right temple cancer lesion and cover with Primapore.7/15/2025- Imiquimod external cream 5% (a topical medication used to treat certain skin conditions, including basal cell carcinoma apply to right temple every other day.9/4/2025- Metronidazole external gel 0.75 % (an antibiotic medication used to treat various infections caused by bacteria and parasites) apply to the right side of head every other day. Record review of the weekly skin checks from 12/13/2024 through 9/7/2025 failed to reveal evidence that the resident had a right temple wound/lesion. Record review of a nursing progress note dated 9/7/2025 revealed that the resident was sent to the hospital as maggots were found in the right temple wound. The resident was admitted to the hospital with squamous cell carcinoma of right temple with maggots present. Record review of a nursing progress note dated 9/7/2025, authored by Licensed Practical Nurse (LPN), Staff A, indicated that the resident kept picking at the wound. Additionally, the note revealed that Staff A noticed some bloody drainage leaking onto the resident's face and right hand from the wound. When Staff A attempted to clean the wound and the resident's face, she observed some pulsating worms moving inside of the wound, so s/he was transferred to an acute care hospital. Record review of the hospital admission document dated 9/7/2025 revealed that the resident was transferred to the Emergency Department (ED) with a large right-sided wound on the temple which was infested with many maggots. Additionally, the document revealed that the resident was actively picking at the wound while in the ED. Further, it indicated that the wound was irrigated, and many maggots/fly larvae (eggs from the flies) were removed from it.Further hospital documentation revealed that the family member denied MOHS surgery and thought the lesion was being managed conservatively with ointments and topical creams at the nursing home. The note indicates that initially .the patient had a intact skin barrier with no breakage or infestations. But slowly over the course of the last six months the wound marking started to fall out and a full-blown hollow wound was formed . Additional review of this paperwork revealed a 3.5-centimeter lesion with necrotic components at right temporal-parietal region adjacent to the ear and the patient will be referred for resection and skin flap advancement by plastic surgery. During a surveyor interview on 9/9/2025 at 1:39 PM and 9/16/2025 at approximately 12:30 PM with Licensed Practical Nurse, Staff A, she revealed the resident has a cancerous lesion which was found during a dermatology consult a few months ago but got worse over time as the resident kept picking at it. Additionally, Staff A disclosed that the resident had a physician's order to apply Aquaphor ointment to the right temple for two weeks from January to February. However, after the treatment ended, the lesion was left untreated until June, when a topical antibiotic was finally started due to the wound's condition. Further, Staff A revealed on 9/7/2025 she observed maggots in the wound and sent the resident to the hospital. During surveyor interviews on 9/10/2025 at 9:16 AM and on 9/16/2025 at approximately 3:00 PM with the Director of Nursing Services, she acknowledged that the lesion/wound to the resident's right temple had become worse. Additionally, she was unable to provide evidence that the wound was treated or assessed from 2/10/2025 until 6/28/2025. Furthermore, she was unable to provide evidence that the weekly skin checks from 12/13/2024 through 9/7/2025 were accurately completely, as the right temple lesion/wound was not assessed on the weekly skin checks.

Based on record review and staff interview, it has been determined that the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations (including nights and weekends) and emergencies. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 6/26/2025, alleges that Resident ID #1 reported that s/he had a wound vac (a medical device that uses suction to help wounds heal faster) and due to improper care provided by the facility, led to the resident requiring his/her toes to be amputated. Record review revealed Resident ID #1 was originally admitted to the facility in April of 2025 with diagnoses including, but not limited to, osteomyelitis (a bone infection), enterococcus (a bacteria that can cause a variety of infections), and encounter for change and removal of surgical wound dressing. Record review revealed that Resident ID #1 was receiving wound vac therapy to his/her left foot. Review of a facility provided document titled, Facility Assessment dated 1/30/2025, states in part, .Special Treatments and Conditions . - Chemotherapy - Radiation - Oxygen Therapy Suctioning - Tracheostomy care - Ventilator or respirator - BiPAP/CPAP - Behavioral health needs - Active/current substance use disorders - IV medications - Injections - Transfusions - Dialysis - Ostomy Care - Hospice Care - Respite Care\Isolation or quarantine for active infectious disease Further review of the Facility Assessment failed to reveal evidence that services provided included wound vac treatment. During a surveyor interview on 7/1/2025 at approximately 12:15 PM with the Administrator, he revealed that the facility does not provide all the special care services listed in the Facility Assessment. Additionally, he could not provide evidence that the Facility Assessment was updated to include services and resources the facility provided to care for wound vac treatments during Resident ID #1's admission to the facility.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to follow standard precautions to prevent the spread of infection and to ensure a sanitary environment to help prevent the transmission of infections for 1 of 1 resident reviewed with a surgical wound, and an indwelling medical device, Resident ID #1. Findings are as follows: Record review of a facility policy titled Enhanced Barrier Precautions [EBP] Policy and Procedure dated March 27, 2024, states in part .EBP are recommended for residents with indwelling medical devices or wounds .a physician order is obtained for EBP for residents with .wounds and/or indwelling medical devices .gown and gloves will be available immediately near or outside the residents room .position a trash can inside the residents room and near the exit to discard PPE [protective personal equipment- such as gown,gloves and masks] after removal and prior to exit of the room . Record review revealed Resident ID #1 was readmitted to the facility in June of 2025 with diagnoses including, but not limited to, osteomyelitis (a bone infection), enterococcus (bacteria that can cause a variety of infections) as the cause of diseases, and encounter for change and removal of surgical wound dressing. Record review of physician's orders revealed the following: - Ceftriaxone sodium (an antibiotic prescribed to treat bacterial infections) 2 grams intravenously once daily for antibiotic treatment. - Vancomycin HCI Intravenous Solution (an antibiotic prescribed to treat serious bacterial infections) 750 milligrams per 150 milliliters solution once daily for osteomyelitis - Cleanse abdominal wound with normal saline, apply Xeroform (a type of wound dressing) and then primapore (a water-resistant adhesive dressing designed for wound care) over wound and change the dressing daily Additional review of physician orders failed to reveal evidence of an order for EBP, as indicated, per the facility policy. Record review of a progress note dated 6/28/2025 at 10:56 PM revealed, the resident was receiving care for a below the ankle amputation. S/he had a peripherally inserted central catheter (PICC, a long, thin, flexible tube inserted into a vein in the arm, usually above the elbow, and guided into a large vein near the heart) on his/her right arm, and receives Vancomycin and Ceftriaxone antibiotic treatments intravenously through the PICC. Surveyor observations on 7/1/2025 failed to reveal evidence that gowns and gloves were immediately available near or outside of the resident's room, or that a trash can was inside the residents room and near the exit to discard PPE after removal and prior to exiting the residents room. During a surveyor interview with the resident on 7/1/2025 at 2:17 PM, s/he revealed that staff have not worn gowns when providing personal care to him/her. During a surveyor interview on 7/1/2025 at approximately 3:40 PM with Registered Nurse, Staff A, she revealed that the resident should have been on EBP due to his/her wounds and the presence of a PICC line. During a surveyor interview on 7/1/2025 at 4:02 PM with the Director of Nursing Services, she revealed it would be her expectation that the resident would have EBP in place as indicated by the presence of wounds and an indwelling medical device.

Based on record review and staff interview, it has been determined that the facility failed to keep a resident free from abuse for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health (RIDOH) on 3/31/2025, revealed in part, that Resident ID #1 became combative with staff and was escorted to his/her room and that the resident was held down in his/her bed to avoid him/her from falling. Additionally, the incident report dated 3/31/2025, revealed that a follow up call was placed from RIDOH to the facility, where the Director of Nursing Services (DNS), revealed that Registered Nurse (RN), Staff A, and Licensed Practical Nurse (LPN), Staff B, restrained Resident ID #1. Review of the facility policy titled, Abuse Prevention Plan reviewed 10/23 states in part, .Abuse is defined as .the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .It includes verbal abuse, sexual abuse, physical abuse, and mental abuse .convenience is defined as the result of any action that has the effect of altering a resident's behavior such that the resident requires a lesser amount of effort or care, and is not in the resident's best interest .freedom of movement means any change in place or position for the body or any part of the body that the person is physically able to control .manual method means to hold or limit a resident's voluntary movement by using body contact as a method of physical restraint .physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all the following criteria .Restricts the resident's freedom of movement or normal access to his/her body . Record review revealed Resident ID #1 was readmitted to the facility in January of 2025 with diagnoses that include, but are not limited to, dementia and anxiety disorder. Review of an Admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 0 out of 15, indicating the resident has severely impaired cognition. Review of the resident's care plan revealed that s/he is at risk for selfcare deficit related to weakness and deconditioning related to advanced dementia with the following interventions in place; if resistive to care, redirect and reapproach at a later time and approach the resident in a calm friendly manner for daily care. Review of the resident's progress notes revealed that on 3/31/2025, at approximately 7:30 PM, RN, Staff C, was on the unit when Resident ID #1 was noted to be agitated and aggressively attempting to enter the room of another resident. Staff A, was assisting him/her out of the other resident's room and escorted Resident ID #1 to the common area. RN, Staff C, left the unit and was called back for Resident ID #1 being out of control and that s/he was combative and was attempting to fight everyone. Staff C, and Staff B, went back to the unit to assist. Resident ID #1 was found sitting in the common area, extremely agitated and combative, throwing his/her walker at staff, kicking, biting, and punching anyone that was in his/her reach. Staff were told to back away from him/her; however, the resident got up and was attempting to head in the direction of other residents. Staff C removed the other residents from the immediate situation and called Emergency Medical Services (EMS) for assistance. At this time LPN, Staff B, and Nursing Assistants (NA), Staff D and E, escorted Resident ID #1 out of the common area and into his/her bed. The NA's left the room and Staff C stayed behind with the resident while Staff B attempted to keep him/her safe until help arrived. Resident ID #1 began kicking and spitting. Staff C, and Staff B, tried to calm the resident down by offering him/her ice cream and music, to which s/he took a mouthful of and spit it across the room. Police and EMS arrived shortly after and without incident, the resident was transferred to the hospital for a work-up. During a surveyor interview on 4/7/2025 at 11:05 AM, with RN, Staff C, she revealed that on 3/31/2025 she received a call from a staff member on Resident ID #1's unit who indicated that the resident was out of control. She further revealed that she and LPN, Staff B, went to the unit to assist. She revealed that upon arrival to the unit she found Resident ID #1 sitting in a chair in the common area with his/her walker in front of him/her and the resident appeared terrified. She revealed that the resident attempted to throw his/her walker at her, so she removed the other residents from the area. She revealed that when she went back to the resident s/he was being assisted from the chair in the common area to his/her room by NA's, Staff D, E, and ,Staff B. She revealed that while the other staff was assisting Resident ID #1 back to his/her room she left to get the resident an ice cream and mats for the floor in case of a fall and went back to his/her room. Upon entering the resident's room she observed LPN, Staff B, push the resident into bed and held him/her down with her hand on the resident's chest. She revealed that she told Staff B to stop and Staff B responded, No [s/he] is not going to act like that. She further revealed that she continued to tell the Staff B to stop. The resident then began to spit at the staff and she revealed that Staff B, held the resident's head to the side with her palm on the side of the resident's head behind his/her ear. She further revealed that she sent both Staff A and B home on 3/31/2025, following the above incident of witnessed abuse. During a surveyor interview on 4/7/2025 at 12:57 PM with NA, Staff D, she revealed that on 3/31/2025 she witnessed RN, Staff A, dragging Resident ID #1 down the hallway by pulling his/her arm and walker. She then observed Staff A to forcefully push the resident into a chair. She revealed that the resident attempted to hit her with his/her walker and stomp on her foot. She revealed another staff member came over to assist by removing the walker from the resident and then the resident bit that staff member's arm. Staff D, revealed that Staff A, then pushed the resident's head backwards to stop him/her from biting. She revealed that at this point RN, Staff C and LPN, Staff B, arrived on the unit. Staff B, brought the resident to his/her room by pulling the resident towards the room and Staff B, said to the resident, you're going to get hurt more than I will. She revealed that she told the staff to stop and attempted to hold the resident's hands to walk him/her down the hall. However, Staff B, continued to pull the resident aggressively and forced him/her into bed. During a surveyor interview on 4/8/2025 at 9:42 AM, with NA, Staff E, she revealed that on 3/31/2025 she was coming out of the shower room on the unit when she saw RN, Staff A, dragging the resident down the hallway by pulling his/her arm and walker. She indicated that the resident looked scared. She then observed Staff A pick up the resident and tossed [him/her] into the chair. She stated that she told the nurse to walk away and take a break. She revealed that after she completed care on another resident, she returned to the common area to check on Resident ID #1 where she observed LPN, Staff B, dragging the resident to his/her room, and Staff E, told LPN, Staff B, to leave the resident alone. She revealed that Staff B, continued to bring the resident to his/her room and that the resident attempted to pull away and almost fell . She stated when they got into the room Staff B, threw [him/her] into the bed and pinned [him/her] into the bed by [his/her] head. She further revealed that she continued to tell Staff B, that the resident was in a safe space and to leave him/her alone. Review of a document titled, Employee Disciplinary Record dated 4/3/2025 for RN, Staff A, revealed that he was terminated due to his failure to follow appropriate procedure while trying to seat a combative resident by physically moving a resident to the chair with unnecessary force which was witnessed by multiple co-workers. Review of a document titled, Employee Disciplinary Record dated 4/3/2025 for LPN, Staff B, revealed that she was terminated due to failing to follow the appropriate procedure by physically restraining a combative patient. Staff B was witnessed holding a resident's head down while the resident was in bed to prevent him/her from getting up. Record review of the facility investigation report dated 4/1 and 4/2/2025 revealed that the facility substantiated the allegation of abuse and both Staff A and B were terminated. During a surveyor interview on 4/8/2025 at 10:32 AM with the DNS, she revealed that she substantiated the allegation of abuse. She revealed that she would have expected the staff to redirect the resident and monitor him/her from a distance once s/he was safe. She revealed that she was unsure why the staff continued to attempt to move the resident or remove his/her walker once the resident was in a chair in a common area and would have expected the staff to walk away. Additionally, she revealed that she would have expected the staff to not restrain the resident in bed, but rather leave him/her alone as s/he was safe. Furthermore, she acknowledged that Resident ID #1 was abused on 3/31/2025. The survey team concluded that a reasonable person would not want to be dragged down the hallway, tossed into a chair or thrown and pinned into his/her bed and therefore this was cited at a the harm level due to the probability of psychosocial harm.

Based on record review and staff interview, it has been determined that the facility failed to develop and maintain policies and procedures for the facility to act on pharmacy identified irregularities marked as Clinical Priority) for 1 of 1 resident reviewed for the use of Clozapine (Clozaril, an atypical antipsychotic medication prescribed for treatment-resistant schizophrenia, recurrent suicidal behavior in schizophrenia), Resident ID #1. Findings are as follows: Review of an article published by the National Library of Medicine, nlm.nih.gov dated 7/1/2019 reveals that abrupt discontinuation of Clozapine has the risk to cause seizures, rebound psychosis, cholinergic rebound (profuse sweating, headache, nausea, vomiting, and diarrhea), serotonin syndrome (agitation, insomnia, high blood pressure, rapid heart rate), and catatonia (a neuropsychiatric syndrome characterized by abnormal movements and behaviors). Review of a community reported complaint submitted to the Rhode Island Department of Health on 3/3/2025 alleged that Resident ID #1 had his/her psychiatric medication stopped without a physician's order and subsequently was admitted to the hospital on 2/3/2025. Record review revealed that Resident ID #1 was readmitted to the facility in December of 2024 with diagnoses including, but not limited to, Alzheimer's disease and schizophrenia. Record review revealed that the resident was readmitted to the facility from the hospital on 12/20/2024 with the following medication order: - Clozapine (antipsychotic, Clozaril) 400 milligrams (mg) at bedtime for 30 days Review of the January 2025 Medication Administration Record (MAR) revealed that the above noted medication had a discontinue date of 1/19/2025, due to the hospital order being for 30 days rather than ongoing. Further review of the MAR revealed that the resident did not receive the above ordered medication for 11 days. Review of a Pharmacy Consultation Report dated 1/28/2025 revealed, Clinical Priority Recommendation: Prompt Response Requested .Should the resident still be receiving a bedtime dose of Clozaril? Additional review revealed that Nurse Practioner (NP), Staff A, signed this recommendation on 2/3/2025 with a note stating, Resident should continue Clozaril per order . Review of a progress note dated 2/3/2025 states in part, Resident continues with suicidal ideation, medication refusal, and self-injurious behaviors. [S/he] was found in a geri-chair with a blanket over [his/her] face attempting to induce vomiting by shoving [his/her] fingers down [his/her] throat. When asked why [s/he] was trying to make [her/himself] vomit, [s/he] stated [s/he] was trying to get the toxins out. [S/he] was also found to have toilet paper stuffed in both [his/her] ears and was attempting to swallow tissues to absorb the toxins. Resident refused all medications this evening, despite reinforcement .Resident declining, harmful to [him/herself] and unable to safely remain at facility without 1:1 supervision . Record review revealed that the resident was inpatient on the psychiatric unit at the hospital from 2/3/2025 until 3/6/2025. During a surveyor interview on 3/20/2025 at 10:09 AM with Staff A, she revealed that the Clozaril should have continued as ordered. Additionally, she revealed that the 30 day stop date was put in place in error. The NP further acknowledged that she signed the pharmacy recommendation dated 1/28/2025 on 2/3/2025 the same day that the resident had been transferred to the hospital. During a surveyor interview on 3/20/2025 at 11:00 AM with Registered Nurse, Staff B, she revealed that when the pharmacy does a review the nurses on the unit receive the recommendations in a folder for the providers to sign. Per Staff B, there is no system in place to highlight priority recommendations that require a prompt response. During a surveyor interview on 3/20/2025 at 11:16 AM with the Director of Nursing Services (DNS), she revealed that the pharmacy recommendations marked as Clinical Priority should have been reviewed with the provider within 24 hours of the date that the recommendation was made. The DNS was unable to provide evidence that the irregularity report was acted upon within 24 hours of the 1/28/2025 recommendation date. The facility's failure to have a system in place to ensure that pharmacy reports that require a prompt response are acted upon accordingly, places all of the facility's residents at risk for serious injury, serious harm, serious impairment or death. Cross reference F-760

Based on record review and staff interview it has been determined that the facility failed to keep all residents free from significant medication errors for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of a policy titled Medication Reconciliation dated 5/13/2019 states in part, .Medication Reconciliation will occur for each patient/resident upon admission/re-admission or re-entry from the hospital to [Facility] to ensure safe and effective administration of medications .For a patient/resident who was sent to the hospital by [Facility] and is re-entering [Facility] after that hospital stay, the admitting nurse will: Review the Continuity of Care Form and clinical record from the discharging hospital and compare that Continuity of Care Form and clinical record with the medications the patient/resident was receiving prior to the hospitalization . Review of an article published by the National Library of Medicine, nlm.nih.gov dated 7/1/2019 reveals that abrupt discontinuation of Clozapine (Clozaril, an atypical antipsychotic medication prescribed for treatment-resistant schizophrenia, recurrent suicidal behavior in schizophrenia) has the risk to cause seizures, rebound psychosis, cholinergic rebound (profuse sweating, headache, nausea, vomiting, and diarrhea), serotonin syndrome (agitation, insomnia, high blood pressure, rapid heart rate), and catatonia (a neuropsychiatric syndrome characterized by abnormal movements and behaviors). Review of a community reported complaint submitted to the Rhode Island Department of Health on 3/3/2025 alleged that Resident ID #1 had his/her psychiatric medication stopped without a physician's order and subsequently was admitted to the hospital on 2/3/2025. Record review revealed that Resident ID #1 was readmitted to the facility in December of 2024 with diagnoses including, but not limited to, Alzheimer's disease and schizophrenia. Record review revealed that the resident was readmitted to the facility from the hospital on 12/20/2024 with the following medication orders: - Clozapine 400 milligrams (mg) at bedtime for 30 days - Trazadone 50 mg at bedtime for 30 days - Folic Acid 1 mg daily for 30 days - Lasix 20 mg daily for 30 days - Potassium Chloride 20 milliequivalents daily for 30 days Review of an Order Summary Report revealed that the resident was receiving all of the above noted medications prior to his/her hospitalization in December of 2024. Further record review failed to reveal evidence that the facility completed a medication reconciliation upon his/her readmission, including comparing the medications from the hospital, with the medications received prior to hospital admission per the facility's policy. Additionally, the facility failed to further review each medication that indicated a 30-day time frame with the provider and transcribed each ordered medication with a stop date of 30 days without clinical reason. Review of the January 2025 Medication Administration Record (MAR) revealed that the above noted medications had a discontinue date of 1/19/2025, due to the hospital order being for 30 days rather than ongoing. Despite Resident ID #1 being seen by a Psychiatric Practitioner on 1/14/2025 which revealed a recommendation to continue with Clozapine 400 mg and Trazadone 50 mg at bedtime. Additionally, it revealed that the Nurse Practitioner (NP), Staff A, agreed with the recommendations, indicating that the recommendations should have been transcribed as an order. Record review failed to reveal evidence that the end date for the Clozapine and Trazadone were updated for continued administration, as ordered by Staff A. Record review of a progress note dated 1/30/2025 revealed that Resident ID #1 was having increased delusions and paranoia. At that time, a medication review was completed by the nurse, and it was identified that s/he was not receiving his/her prescribed dose of Clozapine 400 mg or Trazadone 50 mg. Further review of the January 2025 MAR revealed that on 1/31/2025 all of the above-mentioned medications were resumed. Review of a progress note dated 2/3/2025 states in part, Resident continues with suicidal ideation, medication refusal, and self-injurious behaviors. [S/he] was found in a geri-chair with a blanket over [his/her] face attempting to induce vomiting by shoving [his/her] fingers down [his/her] throat. When asked why [s/he] was trying to make [her/himself] vomit, [s/he] stated [s/he] was trying to get the toxins out. [S/he] was also found to have toilet paper stuffed in both [his/her] ears and was attempting to swallow tissues to absorb the toxins. Resident refused all medications this evening, despite reinforcement .Resident declining, harmful to [him/herself] and unable to safely remain at facility without 1:1 supervision . Record review revealed that the resident was admitted to the hospital on 2/4/2025 with suicidal ideation, paranoia, visual, olfactory (smell) and auditory hallucinations. S/he was inpatient until 3/6/2025. During a surveyor interview on 3/20/2025 at 10:09 AM with Nurse Practitioner, Staff A, she acknowledged that the resident had been receiving all of the medications noted above prior to his/her hospital admission in December 2024. The NP acknowledged that the orders transcribed with a 30 day stop date upon readmission was an error. Additionally, she revealed that she would have expected the staff to continue the resident's order for Clozapine 400 mg and Trazadone 50 mg, past the 30 days as recommended by the Psychiatric Practitioner and approved by her. During a surveyor interview on 3/20/2025 at 11:16 AM with the Director of Nursing Services (DNS) she acknowledged that the resident's Clozapine, Trazadone, Folic Acid, Lasix and Potassium Chloride were transcribed with a 30 day stop date in error. Additionally, the DNS was unable to provide evidence that a medication reconciliation was completed for the resident per the facility policy. The DNS was unable to provide evidence that the resident was kept free from significant medication errors. The facility's failure to conduct a medication reconciliation upon the resident's re-admission to the facility, resulted in the resident not receiving his/her necessary medications. This failure resulted in the resident's transfer and month long admission to an acute hospital for treatment, after experiencing suicidal ideation's and delusions. these failures placed Resident ID #1 at risk for serious injury, serious harm, serious impairment, or death. Cross Reference F 756

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety relative to the main kitchen. Findings are as follows: 1. The [NAME] Food Code, 2018 Edition, 4-601.11 states in part, .Nonfood contact surfaces shall be kept free of an accumulation of dirt, dust, food residue, and other debris . During surveyor observations on 10/20/2024 at 8:50 AM, 10/21/2024 at 12:41 PM and 10/23/2024 at approximately 2:00 PM of the main kitchen on the following was observed: -Dust and grease accumulation on the [NAME] hood system, including the spray heads and light fixtures. -Dust and grease accumulation along the sides of the stove. -Dust and grease accumulation along the inner front of the flat top griddle. -Corners of the convection oven with an accumulation of grease and grime. -the floor behind all kitchen equipment, including worktables and the ice machine had an accumulation of dust and debris. 2. The Rhode Island Food Code, 2018 Edition, 2-302.11 Fingernails Maintenance states in part, .unless wearing intact gloves in good repair, a food employee may not wear fingernail polish or artificial fingernails when working with expose food . During surveyor observations on 10/20/2024 at 8:50 AM, 10/21/2024 at 12:41 PM and 10/23/2024 at approximately 2:00 PM of the main kitchen, Dietary Cook, Staff I, was observed with acrylic nails while working in the main kitchen without wearing gloves. 3. The [NAME] Food Code 2018 Edition 5-501.113 Covering Receptacles states in part, .receptacles shall be kept covered .and are not in continuous use . During surveyor observations on 10/20/2024 at 8:45 AM, 10/22/2024 at 12:41 PM and 10/23/2024 at 2:00 PM of the main kitchen the following was observed: -A trash container with refuse that was stored by a bread rack was uncovered and not in use. -A trash container with refuse that was stored by a worktable across from the convection oven was uncovered and not in use. During a surveyor interview on 10/24/2024 at approximately 11:30 AM with the Food Service Director, he acknowledged the large equipment and the hood over the stove was in need of cleaning, that the dietary cook had acrylic nails and was not wearing gloves during any type of food preparation and/or service and that the trash containers were not covered in the main kitchen when they were not in use.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents with pressure ulcers receive the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 4 residents reviewed for pressure ulcers, Resident ID #s 38 and 153. Findings are as follows: Record review of a facility policy dated May of 2019 titled, Skin Integrity Management states in part, all residents receive care, consistent with professional standards of practice, to prevent pressure ulcers so they do not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable .the care plan is developed based on the resident assessment .The care plan includes, for a resident who has skin integrity issues or pressure injury or is at risk for pressure injury .skin check are completed and documented by a nurse weekly . 1. Record review revealed that Resident ID #153 was readmitted to the facility in January of 2024 with diagnoses including, but not limited to, stroke with left hemiplegia (a symptom that involves one-sided paralysis) and hemiparesis (one sided muscle weakness). Record review of the Annual Minimum Data Set Assessment (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) with a score of 7 out of 15, indicating the resident has severe cognitive impairment. Record review of the resident's care plan dated 1/20/2024 revealed the resident is at risk for impaired skin integrity related to incontinence with an intervention including, but not limited to, utilize pressure relieving devices on appropriate surfaces. Record review revealed a physician's order dated 9/3/2024 to offload heels (relieve pressure) at all times. Record review of a Skilled Wound Care Surgical Note dated 10/15/2024 indicated that the resident has a Deep Tissue Pressure Injury (DTI-a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) to his/her left heel. Surveyor observations on the following dates and times failed to reveal evidence that the resident's heels were offloaded as ordered: -10/21/2024 at approximately 11:30 AM -10/22/2024 at 9:37 AM -10/23/2024 at 8:59 AM During a surveyor interview on 10/24/2024 at 10:44 AM with Licensed Practical Nurse (LPN), Staff E, she acknowledged that the resident has an order for his/her feet to be off loaded and that the staff failed to off load his/her heels per the physician order. 2. Record review revealed that Resident ID #38 was admitted to the facility in January of 2019 with a diagnosis including, but not limited to, protein calorie malnutrition (a state of inadequate intake of food as a source for protein and calories). Record review of a Braden Scale for predicting pressure sore risk dated 4/29/2024 revealed a score of 15 out of 18, indicating the resident is at risk for the development of pressure injuries. Record review revealed a physician's order dated 8/13/2024 to off load both heels every shift for prevention of skin breakdown. Surveyor observations on the following dates and times failed to reveal evidence that the resident's heels were off loaded as ordered: -10/20/2024 at 10:01 AM and 11:40 AM -10/21/2024 at 9:10 AM and 11:30 AM -10/22/2024 at 9:30 AM and 11:08 AM -10/23/2024 at 9:00 AM During a surveyor interview on 10/23/2024 at 9:12 AM with LPN, Staff F, she acknowledged that Resident ID # 38's heels were not offloaded during the above-mentioned observations. During a surveyor interview on 10/23/2024 at approximately 1:00 PM and on 10/24/2024 at 1:03 PM with the Director of Nursing Services, she indicated that she would expect the staff to follow the physician's orders for offloading heels.

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 3 of 3 residents reviewed for wound care, Resident ID #s 77,153, and 162. Additionally, the facility failed to maintain Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO] in nursing homes) for 2 of 4 residents reviewed with pressure injuries, Resident ID #s 77 and 146. Findings are as follows: 1. According to the Infection Control Assessment and Response (ICAR) Tool for General Infection Prevention and Control (IPC) Across Settings .Wound Care Facilitator Guide from the Centers for Disease Control and Prevention last revised on 1/27/2023, states in part, .Maintain separation between clean and soiled equipment to prevent cross contamination .Any unused disposable supplies that enter the patient/resident's care area should remain dedicated to that patient/resident or be discarded. They should not be returned to the clean supply area. If supplies are dedicated to an individual patient/resident, they should be properly labeled and stored in a manner to prevent cross-contamination or use on another patient/resident (e.g., in a designated cabinet in the patient/resident's room) .Containers entering patient/resident care areas should be dedicated for single-patient /resident use or discarded after use . 1a. Record review revealed Resident ID #77 was admitted to the facility in August of 2017 with a diagnosis including, but not limited to a pressure ulcer of the sacral region. Record review revealed a physician's order dated 10/9/2024 to clean coccyx area wound with Vashe (an anti-septic cleaner). Apply a collagen dressing with silver into wound and areas of tunneling followed by a Vashe soaked 2x2 dressing. Apply Triad (a cream that is used to absorb moderate levels of wound exudates) to peri wound (surrounding skin of wounds). Apply skin protectant to wound edges followed by a sacral bordered foam dressing and change daily. During a surveyor observation of the coccyx wound dressing on 10/23/2024 at approximately 11:00 AM with Licensed Practical Nurse, (LPN), Staff E, she failed to change her soiled gloves and perform hand hygiene between cleaning the wound and before placing the collagen dressing with silver into the resident's wound. During a surveyor interview with Staff E immediately following the above observation, she acknowledged she did not change her gloves and/or perform hand hygiene after cleaning the wound and before placing the collagen dressing with silver into the resident's wound. 1b. Record review revealed Resident ID #153 was readmitted to the facility in January of 2024 with diagnoses including, but not limited to, type 1 diabetes mellitus and hemiplegia (a symptom that involves one-sided paralysis) affecting left non-dominant side. Record review revealed a physician's order dated 10/23/2024 to cleanse the left heel with normal saline followed by betadine twice daily. During a surveyor observation of the left heel treatment on 10/23/2024 at 11:26 AM with Staff E, she failed to change her soiled gloves and perform hand hygiene between cleaning the wound with normal saline and prior to the application of the betadine to the wound. During a surveyor interview with Staff E following the above observation, she acknowledged that she failed to change her soiled gloves and perform hand hygiene between cleaning the wound with normal saline and prior to the application of the betadine to the wound. 1c. Record review revealed Resident ID #162 was readmitted to the facility in June of 2024 with a diagnosis including, but not limited to, cellulitis (skin infection). Record review revealed a physician's order dated 9/17/2024 to cleanse wounds on T-spine proximal, distal (upper back), and right scapula with normal saline followed by calcium alginate, extra protective cream to surrounding skin of the wound followed by a large foam dressing daily. During a surveyor observation of the dressing change on 10/23/2024 at 9:36 AM with LPN Staff H, the following was observed: - Staff H placed the resident's soiled dressing on top of his/her bed instead of discarding it in the trash. - Staff H used his index finger to put a medication into the resident's wound and failed to use an applicator. - Staff H failed to remove his soiled gloves and perform hand hygiene after completing the resident's dressing change then proceeded to touch multiple items in the resident's room including the call light and the bed remote. During a surveyor interview on 10/23/2024 at 9:52 AM with Staff H , he acknowledged that he failed to change his soiled gloves and perform hand hygiene prior to touching the above mentioned items in the resident's room, failed to use an applicator to apply the medication to the resident's wound, and placed the visibly soiled dressing on the residents bed. During a surveyor interview on 10/23/2024 at 11:56 AM with the Director of Nursing Services (DNS), she revealed that she would expect the nurses to follow infection control guidelines and remove their dirty gloves and perform hand hygiene before touching multiple items in the room. 2. Review of the Centers for Medicare and Medicaid Services memorandum dated 3/20/2024 with a subject of Enhanced Barrier Precautions in Nursing Homes to Prevent Spread of MDROs states in part, .EBP are indicated for residents with any of the following: .Wounds .even if the resident is not known to be infected or colonized with MDRO .Has a wound .and secretions or excretions that are unable to be covered and contained and are not known to be infected or colonized with any MDRO . Record review of the facility policy dated 3/27/2024 titled Enhanced Barrier Precautions Policy and Procedure states in part .Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition .High-contact resident activities include .Wound care: any skin opening requiring a dressing . 2a. Record review for Resident ID #77 revealed s/he has a pressure ulcer to his/her sacrum with current treatment orders. During a surveyor observation on 10/22/2024 at 9:44 AM revealed the facility failed to place Resident ID #77 on EBP precautions. During a surveyor observation on 10/23/2024 at approximately 11:00 AM, LPN Staff E, and Certified Medication Technician (CMT) Staff G failed to wear protective gowns during the coccyx dressing change. During a surveyor interview on 10/23/2024 at approximately 11:20 AM with Staff E, she revealed that she was unaware that the resident was supposed to be on EBP and/or that she needed to wear a protective gown during the resident's coccyx wound dressing change. 2b. Record review revealed Resident ID #146 was readmitted to the facility in February of 2024 with a diagnosis including, but is not limited to, pressure-induced deep tissue damage of right heel. Record review of a physician's order dated 10/16/2024 states in part, . to cleanse right heel wound with normal saline, pat dry, apply nickel thick Santyl (a medication that removes dead tissue from wounds) followed by a calcium alginate dressing (wound dressing that absorbs moisture and promotes healing), cover with ABD (absorbent dressing), and wrap with Kling. Surveyor observations made on 10/21/2024 at 9:14 AM and 1:30 PM, and on 10/23/2024 at 12:04 PM, failed to reveal evidence that the resident was placed on EBP. During a surveyor interview on 10/23/2024 at 12:06 PM with Staff E, she revealed that she was unaware that Resident ID #146 was supposed to be placed on EBP. During a surveyor interview on 10/24/2024 at 11:16 AM with the Infection Preventionist, she acknowledged that both Resident ID #s 77 and 146 had open wounds and should have been placed on EBP. 47939

Based on record review and staff interview, it has been determined that the facility failed to ensure that a Nurse Practioner provide orders for the resident's immediate care and needs for 1 of 1 resident reviewed for physician orders with acute urinary retention (inability to empty the bladder) Resident ID #153. Findings are as follows: Record review revealed Resident ID #153 was admitted to the facility in October of 2023 with diagnoses including, vascular dementia (a type of dementia cause by brain damage from impaired blood flow) and cerebrovascular disease (a term for conditions that affect blood flow to your brain). Record review of a progress note dated 10/21/2024 authored by Nurse Practitioner (NP), Staff J, documented as a late entry for 10/17/2024 states in part, .Patient was noted with abnormal weight gain, increased edema as well as hypotension and at that time last week this writer ordered bladder scans,[s/he] was noted to be retaining urine again and a foley catheter was inserted, unfortunately a urine was not sent to the lab for culture and sensitivity as was ordered, on exam today that patient was slurring words and very disoriented from [his/her] baseline, nursing will need to obtain a urine and send it to the lab for culture and sensitivity as [s/he] is likely has an acute cystitis [bladder infection] . Record review of the physician's orders failed to reveal evidence that an order was written for a urine culture and sensitivity. During a surveyor interview on 10/24/2024 at 1:03 PM, with Licensed Practical Nurse, Staff E she revealed that she was not aware that the resident required a urine culture and sensitivity. During a surveyor interview on 10/24/2024 at 11:46 AM with Staff J, she acknowledged that she failed to provide an order to obtain a urine culture and sensitivity prior to 10/17/2024 or on 10/17/2024 when she noted the resident to have an acute change in condition. During a surveyor interview with the Medical Director on 10/24/2024 at 4:21 PM, he indicated that he would expect the NP to follow up and provide an order for a urine culture and sensitivity for the resident. 47939

Based on record review, resident and staff interviews, it has been determined that the facility failed to ensure that each resident receives adequate supervision to prevent accidents, for 1 of 3 residents reviewed for falls resulting in transfer to a hospital, Resident ID #62. Findings are as follows: Record review of a facility policy titled, FALLS REPORTING last reviewed 11/2023, states in part, POLICY: [Facility] is committed to providing an environment that is free from accident hazards over the which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents by identifying, evaluating and analyzing risks/hazards; implementing interventions to reduce risks/hazards; and monitoring for effect and modifying interventions as necessary. Falls with or without injury will be investigated and reported as follows: PROCEDURE .5. The licensed nurse will completely fill out the Event Report in [the electronic health record] and begin a through investigation as to why the fall occurred, including interview of staff involved .6. Obtain written statements from staff caring for resident that shift .9. The licensed nurse will initiate or revise the care plan as necessary and review with nursing staff .10. Falls will be reviewed Monday-Friday at the daily meeting of the IDT [Interdisciplinary Team] for appropriate follow up .12. Falls will be tracked and trended and reported to the Quality Assurance/Performance Improvement [QAPI] Committee at each quarterly meeting . Record review revealed the resident was admitted to the facility in November of 2021 with diagnoses including, but not limited to, repeated falls, morbid obesity, and generalized muscle weakness. Review of an annual Minimum Data Set assessment dated [DATE] revealed the resident requires extensive assistance of 2 or more people while turning side to side from a lying position. Review of a care plan initiated on 8/14/2022 revealed the resident is at risk for falls/injury related in part to muscle weakness and limited range of motion of his/her right shoulder with interventions that include, but are not limited to, full body mechanical lift (hoyer) with 2 assist and .S/P [status post] fall 10-13-23 shower trolley [A stretcher-like, piece of mechanical equipment that provides support to those bathing who have low mobility] removed from unit maintenance to evaluate., the latter intervention initiated on 10/13/2023, the day of the resident's fall. Further review of the care plan failed to reveal evidence that a shower trolley is used for bathing the resident or how many staff members are required to assist the resident while using it to ensure his/her safety. Review of the Facility Assessment last updated in March of 2023, failed to reveal evidence that a shower trolley is a piece of equipment utilized by the facility. Record review revealed the following progress notes: -10/13/2023 at 11:04 AM states in part, 10:40 AM - Resident had a witnessed fall out of the shower trolley in the shower room onto the floor. Upon entering shower room resident observed with pooling blood from below [his/her] facial area .vertical laceration to mid forehead noted and dressed with pressure dressing by paramedics. Resident transferred out .to [hospital] . -10/14/2023 at 3:15 PM states in part, .returned from [hospital] last night with eleven dissolvable stitches to forehead .observed to have bruising around right eye. Edema [swelling] also observed above laceration and to the sides of laceration .Bruising is also observed above laceration and to bilateral sides of laceration. Right eye is observed red and irritated .partially closed due to swelling .observed to have bruising to right knee also .Resident states that [s/he] is very tired from yesterday's traumatic experience . During a surveyor interview with the resident on 1/8/2024 at 1:11 PM and again on 1/9/2024 at approximately 2:00 PM, the resident revealed that s/he had a fall from a shower trolley when attempting to turn from a lying position to his/her left side. S/he further indicated that when pulling on the side rail, it felt loose and broke, and s/he remembers waking up on the shower floor face down in a pool of blood. Additionally, s/he further revealed that there were initially 2 nursing assistants (NA) assisting him/her on the day the accident happened, but the second NA had left prior to the completion of his/her shower. Furthermore, s/he revealed that the side of the shower trolley that s/he fell from was the side that the other NA was positioned on. During a surveyor interview on 1/9/2024 at 12:53 PM with NA, Staff B, she indicated that she was verbally told during orientation that the shower trolley should not be used for a resident that weighs over 250 pounds. She further revealed that there should definitely be two staff members assisting a resident receiving a shower with a shower trolley. Review of the resident's weights revealed the following entries: -10/6/2023: 249.8 pounds -11/7/2023: 258.8 pounds During a surveyor interview on 1/9/2024 at 1:04 PM with the Staff Development Coordinator, she revealed that there is no formal training or competency for staff regarding the use of the shower trolley, but it is discussed during the orientation process. She revealed that for a resident utilizing the shower trolley, 2 staff members should be present to assist the resident with turning and repositioning. During a surveyor interview on 1/9/2024 at 4:01 PM with Registered Nurse, Staff C, he revealed that he was the nurse who assessed the resident after the fall was reported to him. He indicated that the number of staff members to assist with a shower trolley bath is based on the resident's cognition and mobility and may require one to two staff members to assist. He further indicated that the shower trolleys are currently still being used for other residents. During a surveyor interview on 1/10/2024 at 9:49 AM with NA, Staff D, she revealed that she was the NA assisting the resident at the time s/he fell from the trolley. She revealed the trolley was only discussed during her orientation; however, she was never instructed on how many staff members are required to safely assist the resident with bathing when using a shower trolley. She indicated she always asks for assistance because she feels it's unsafe having only one staff member present. She further revealed that she had asked another NA to assist her with bathing the resident, but that NA had left before the resident's shower was completed. Additionally, she revealed that since the incident, she ensures at least 2 staff members are present for the resident's safety. Furthermore, she indicated that the Director of Nursing Services (DNS) had a verbal conversation with her regarding the incident, however no written statement was obtained, nor education/training's provided for the staff that she is aware of. During a surveyor interview on 1/11/2024 at 3:29 PM with the Director of Therapy, she revealed that she was unsure how many staff members are required to assist a resident receiving a bath using a shower trolley but thinks it would require two. During a surveyor interview on 1/10/2024 at 10:41 AM with the DNS, she revealed that there is probably not a formal training course provided by the facility for staff that utilize the shower trolley. She indicated that there should be two staff members to assist with a shower trolley bath for a resident if the resident is either heavy or immobile. Additionally, she revealed that she only verbally spoke with Staff D after the fall indicating the accident did not require a follow up investigation because she felt the fall was a result of a mechanical equipment failure. Furthermore, she confirmed that the shower trolley the resident fell from was an Arjo Shower trolley, which is also the same model of the two remaining shower trolleys in the facility. Review of the shower trolley manual titled, Arjo Shower trolley 084021/084023 dated 4/1991, states in part, Safety regulations Always make sure that: equipment is handled by trained staff .Check every week that: all hoses, pipes, connections, braking devices and wheels are undamaged. Every month: examine shower and panel hoses so that no leaks occur. These hoses should be replaced every five years .the equipment must be used in accordance with these safety regulations and instructions. Anyone using the equipment must also have read and understood the instructions in this booklet. During a surveyor interview on 1/10/2024 at 2:56 PM with the Maintenance Director, he revealed that he is unaware that the user manual indicates to inspect the shower trolley weekly per the safety regulations. He was unable to provide evidence that the user manuals safety regulations were being followed by the facility. During a surveyor interview on 1/12/2024 at 11:08 AM, with the Administrator and DNS conducted during the QAPI task, they were unable to provide evidence that Resident ID #62's fall on 10/13/2023 was addressed at the last QAPI meeting held on 10/26/2023 as per policy. Additionally, the Administrator revealed that the facility was inconsistent with preventative maintenance of the shower trolleys. Furthermore, the Administrator and DNS acknowledged that the resident's fall was not investigated nor was there follow up education provided to the staff following Resident ID #62's fall. During a subsequent surveyor interview on 1/12/2024 at 9:10 AM with the DNS, she was unable to provide evidence that the facility took appropriate measures to identify avoidable accident hazards and thoroughly investigated Resident ID #62's fall on 10/13/2023 as per policy to help ensure the safety of other residents who continue to use the shower trolley. Additionally, she was unable to provide evidence that the facility ensured that each resident received adequate supervision and assistance to prevent accidents. Refer to F 726 and F 908

Based on record review, resident and staff interviews, it has been determined that the facility failed to provide sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety for 1 of 3 residents reviewed for falls resulting in a hospital transfer, Resident ID #62. Findings are as follows: Record review revealed the resident was admitted to the facility in November of 2021 with diagnoses including, but not limited to, repeated falls, morbid obesity, and generalized muscle weakness. Review of an annual Minimum Data Set assessment dated [DATE] revealed the resident requires extensive assistance of 2 or more people while turning side to side from a lying position. During a surveyor interview with the resident on 1/8/2024 at 1:11 PM and again on 1/9/2024 at approximately 2:00 PM, the resident revealed that s/he had a fall from a shower trolley when attempting to turn from a lying position to his/her left side. S/he further indicated that when pulling on the side rail, it felt loose and broke, and s/he remembers waking up on the shower floor face down in a pool of blood. Additionally, s/he further revealed that there were initially 2 nursing assistants (NA) assisting him/her on the day the accident happened, but the second NA had left prior to the completion of his/her shower. Furthermore, s/he revealed that the side of the shower trolley that s/he fell from was the side that the other NA was positioned on. During a surveyor interview with NA, Staff B, on 1/9/2024 at 12:53 PM, she indicated that she was told back in 2020, during the nursing assistant orientation program, that the shower trolley should not be used for residents over 250 pounds and stated that, definitely two CNA's are to be present when using the shower trolley. During a surveyor interview with the Staff Development Coordinator on 1/9/2024 at 1:04 PM, she revealed that there is no formal training or competency for staff regarding the use of the shower trolley, but it is discussed during the orientation process. She further revealed that the facility does not have a policy in place for use of the shower trolley. Additionally, she indicated that there should be two staff for hoyer transfers into the shower trolley and two staff if turning or repositioning the resident. During a surveyor interview with NA, Staff F, on 1/9/2024 at 2:57 PM, she revealed that two staff should be present at all times when in the shower room. During a surveyor interview with Licensed Practical Nurse, Staff G, on 1/9/2024 at 3:15 PM, she revealed that she does not know how many staff members are required when using the shower trolley. During a surveyor interview on 1/10/2024 at 9:49 AM with NA, Staff D, she revealed that she was the NA assisting the resident at the time the resident fell from the trolley. She further revealed that she has worked at the facility for 5 years and has used the shower trolley before. Further, she indicated that the only training she received on this piece of equipment was when it was mentioned during her orientation training, however, she was never instructed on how many staff members are required to safely assist the resident with bathing when using a shower trolley. Additionally, she revealed that there was not any education/training's provided for the staff after the resident's fall. During a surveyor interview on 1/10/2024 at 10:41 AM with the Director of Nursing Services, she indicated that there should be two staff members to assist with a shower trolley bath for a resident if the resident is either heavy or immobile. Additionally, she was unable to provide evidence that the facility provided sufficient nursing staff with appropriate competencies and skills sets to provide nursing and related services to assure resident safety relative to shower trolleys. Refer to F 689 and F 908 47279

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed, in accordance with professional standards for food safety relative to the main kitchen and 2 of 3 kitchenettes. Findings are as follows: 1. Record review of the Rhode Island Food Code 2018 edition, Section 3-602.11 Food Labels states, .(B) Label information shall include: (1) The common name of the food . During the initial tour of the main kitchen on 1/8/2024 at 10:23 AM in the presence of the Assistant Food Service Director (AFSD) revealed the walk-in freezer #3 with the following items not labeled or dated: - 7 chicken breasts in a plastic bag. - Pancakes in an opened bag. - An opened bag of approximately 20 chicken nuggets. - A bag of diced chicken. Further observations revealed the following: - The walk-in refrigerator #2, contained an opened box of packaged muffins, approximately 10 left, with drippings of a brown liquid. The shelf above had a container of sour cream that was lying on its side directly above the muffins. - Flour stored in a bin with the scoop lying on top of the bin. - Approximately 20 clean sheet pans were stored wet. 2. Record review of the Rhode Island Food Code 2018 edition, Section 5-202.13 Backflow Prevention, Air Gap, states, An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or nonFOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). - The ice machine lacked evidence of an air gap. During a surveyor interview with the AFSD immediately following the above observations, he revealed that the muffins should have been discarded, and the chicken and pancakes should have been labeled and dated. He also indicated that the bag of pancakes should have been enclosed to reduce the risk of contamination. Additionally, he revealed that the scoop for the flour bin should not have been stored on top of it . He acknowledged the ice machine did not have an air gap and that the pans should not have been stored wet. 3. Record review of the Rhode Island Food Code 2018 edition, Section 4-501.112 states in part, Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90 o[degrees]C [Celsius] (194 o F [Fahrenheit] . Review of the hot water dish machine log on 1/10/2024 at 1:10 PM revealed the following temperatures: - 1/4/2024, 196 degrees F at supper - 1/7/2024, 196 degrees F at lunch - 1/8/2024, 196 degrees F at breakfast During a surveyor observation of the hot water dish machine on 1/10/2024 at 1:14 PM in the presence of the AFSD, the final rinse cycle reached 195 degrees F. Immediately following the observation the AFSD took out a test strip to show the surveyor that the temperature reached 180 degrees F. During a surveyor interview with the AFSD following the above observation he revealed that the test strips are to ensure that the temperature of the hot water dish machine reaches 180 degrees F for sanitizing. This surveyor revealed to the AFSD that the test strips do not indicate if the temperature reaches above 194 degrees F, which would indicate that the water begins to vaporize at this temperature, reducing its ability to properly sanitize. During an additional surveyor observation of the dish machine on 1/12/2024 at 11:50 AM with the FSD, the final rinse cycle was still over 180 degrees, registering 196 degrees F. During a surveyor interview immediately following the above observation the FSD revealed that he was unaware that the temperature of the final rinse should not exceed 194 degrees F and revealed he would notify maintenance or the dish machine company to service the machine. 4. During a surveyor observation on 1/8/2024 at approximately 12:00 PM of the SCU and TCU units kitchenette refrigerator doors, revealed a sign that stated in part, .when storing food or drinks in this refrigerator for residents (only). Please make sure all items are properly labeled and dated with resident's name and room number. All items will be discarded after the 3rd day (72 hours) from which it was dated. Please refrain from removing items from resident's trays and storing them in this refrigerator . During a surveyor observation inside the SCU kitchenette refrigerator on 1/8/2024 at 12:07 PM revealed a pasta dish that was dated 1/2. During a surveyor interview on 1/8/2024 at 12:19 PM with the Medication Technician, Staff J, she revealed the pasta dish should have been discarded a few days ago. During a surveyor observation on 1/8/2024 at 12:33 PM of the TCU kitchenette refrigerator revealed a tuna sandwich without a label or date and 5 mighty shakes without a color coded sticker to indicate the day that they should be discarded. During a surveyor interview following the above observations, the AFSD acknowledged the above items were not labeled or dated and discarded them.

Based on record review and staff interview, it has been determined that the facility failed to assist residents in obtaining routine dental care for 4 of 7 residents reviewed for dental services, Resident ID #s 12, 31, 44, 91, and 94. Findings are as follows: 1. Record review revealed Resident ID #12 was admitted to the facility in January of 2022 with diagnoses including, but not limited to, dementia and altered mental status. Review of a Quarterly Minimum Data Set (MDS) Assessment, dated 10/27/2023, revealed a Brief Interview for Mental Status (BIMS-an assessment tool to identify a resident's cognitive function) score of 99, indicating the resident's cognitive function is severely impaired and that an assessment was unable to be completed. Record review failed to reveal evidence of a completed enrollment form or documentation that dental services were declined. 2. Record review for Resident ID #31 revealed s/he was admitted to the facility in April of 2023 with a diagnosis including, but not limited to, dysphagia (difficulty swallowing). Review of a Quarterly MDS Assessment, dated 12/15/2023, revealed a BIMS score of 11 out of 15, indicating s/he has moderately impaired cognition. Record review failed to reveal evidence of a completed enrollment form or documentation that dental services were declined. 3. Record review for Resident ID #44 revealed s/he was admitted to the facility in January of 2019 with diagnoses including, but not limited to, Alzheimer's disease and dementia. Review of a Quarterly MDS Assessment, dated 11/24/2023, revealed a BIMS score of 3 out of 15, indicating s/he has severely impaired cognition. Review of a progress note dated 8/29/2023, revealed his/her son gave verbal consent for him/her to be assessed by dental services and that an enrollment form was completed. Record review failed to reveal evidence of a completed enrollment form or documentation that dental services were declined on or after 8/29/2023. During a surveyor interview on 1/12/2024 at 8:33 AM with Staff H, Accounts Payable and Staff I, Scheduler, they were unable to locate a completed enrollment form and acknowledged that s/he had not been assessed by dental services on or after 8/29/2023. 4. Record review for Resident ID #91 revealed s/he was admitted to the facility in January of 2023 with diagnoses including, but not limited to, dysphagia and feeding difficulties. Review of a Quarterly MDS Assessment, dated 12/27/2023, revealed a BIMS score of 11 out of 15, indicating s/he has moderately impaired cognition. Record review failed to reveal evidence of a completed enrollment form or documentation that dental services were declined. 5. Record review for Resident ID #94 revealed the resident was admitted to the facility in February of 2021 with a diagnosis including, but not limited to, dysphagia. Record review of an Annual MDS Assessment, dated 12/15/2023, revealed a BIMS Assessment was unable to be completed due to his/her severely impaired cognition. Record review failed to reveal evidence of a completed enrollment form or documentation that dental services were declined. During a surveyor interview on 1/11/2024 at 11:11 AM with the Unit Manager, Staff A, he was unable to provide evidence that the resident had been offered or provided dental services. During a surveyor interview on 1/12/2024 at 10:41 AM with the Clinical Services Director and Director of Nursing Services, it was indicated that all residents are offered dental services upon admission and the record should reflect if they accept or decline services. The DNS was unable to provide evidence of a completed enrollment form for ID #44. Additionally, it was indicated that they would expect the above-mentioned residents to have been assessed by dental services, or have a declination form completed in their medical records. 43376 50004

Based on surveyor observations, 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 COVID-19 and enhanced barrier precautions (EBP) for 2 of 4 nursing units, affecting Resident ID #s 8, 11, 52, 59, 84, and 117. Findings are as follows: Record review revealed upon surveyor entrance to the facility that the facility had 7 positive COVID-19 cases throughout the building. 1. Review of a facility policy titled, ISOLATION PRECAUTIONS, CATEGORIES OF, states in part, .Examples of infections requiring Droplet & Contact Precautions include, but are not limited to SARS-CoV2 (COVID-19) .Gloves and Hand Hygiene .wear gloves (clean, nonsterile) when entering the room .Remove gloves before leaving the room and wash hands immediately with an antimicrobial agent . Surveyor observation on 1/8/2024 at approximately 12:30 PM revealed a sign posted outside the door of Resident ID #59 stated, in part, QUARANTINE DROPLET/CONTACT PRECAUTIONS In addition to standard precautions Staff and Providers MUST .Clean hands: when entering and exiting .Eye Protection (Face shield or goggles) .Gloves .and MUST change between residents . Record review revealed Resident ID #59 was diagnosed with COVID-19 on 1/7/2024, his/her roommate, Resident ID #8, is currently negative for COVID-19. Surveyor observation on 1/8/2024 at 12:36 PM, revealed Nursing Assistant (NA), Staff K, entered the room of Resident ID #s 8 and 59 without performing hand hygiene and failed to don the appropriate personal protective equipment (PPE), wearing only a KN95 mask. Continued surveyor observation revealed Staff K moved the bedside table and set up the lunch tray for COVID-19 positive resident, Resident ID #59. She then went to the doorway to obtain Resident ID #8's lunch tray that was handed to her by another staff member. Staff K then delivered the lunch tray to COVID-19 negative resident, Resident ID #8 and cut up his/her lunch meal. Staff K failed to perform hand hygiene after assisting Resident ID #59 and before assisting Resident ID #8. She then exited the room without performing hand hygiene. During a surveyor interview immediately following the above observation with Staff K, she acknowledged that she failed to perform hand hygiene prior to entering the room, wear the appropriate PPE into the resident's room while assisting Resident ID #59, perform hand hygiene prior to assisting Resident ID #8, and before exiting the isolation precaution room. During a surveyor interview on 1/12/2024 at 11:12 AM with the Infection Preventionist (IP), she indicated that her expectation would be that staff wear the appropriate PPE and perform hand hygiene when entering an isolation precaution room. During a surveyor interview on 1/12/2024 at 11:27 AM with the Director of Nursing Services (DNS), she indicated that her expectation would be that staff perform hand hygiene and wear and change gloves between residents as indicated on the isolation precaution sign posted outside of the resident's door. 2. Review of a Rhode Island Department of Health document titled, COVID-19 Information for Nursing Homes, revised on 6/15/2023, states in part, .In addition to standard precautions for infection prevention and control, the CDC [Centers for Disease Control and Prevention] recommends that nursing homes use empiric based precautions to rule out COVID-19 infection for .close contact exposures .Close Contact Exposures Regardless of Vaccination Status .asymptomatic [producing or showing no symptoms] residents .should wear source control for 10 days . Record review revealed Resident ID #117 was admitted to the facility in March of 2021 with diagnoses including, but not limited to, atrial fibrillation and presence of cardiac pacemaker. Further review of the record revealed his/her roommate, Resident ID #78, is positive for COVID-19. Review of the care plan revealed s/he is at risk for COVID-19 with interventions to encourage social distancing of six feet and to encourage use of masks while out of room as tolerated when required. Surveyor observation on 1/10/2024 at 1:29 PM, revealed Resident ID #117 was in a common area not wearing a mask and seated with approximately three other residents who were not socially distanced six feet apart from him/her. During this observation there were no staff members encouraging Resident ID #117 to wear a mask or socially distance. During a surveyor interview on 1/10/2024 at 03:09 PM with the IP, she revealed they offer masks to everyone and encourage close contacts of positive residents to wear a mask if they come out of their rooms. During a surveyor interview on 1/12/2024 at 1:25 PM with the DNS, she acknowledged that she would expect that staff would be following the resident's plan of care and the facility policy for infection control. She was unable to explain why the resident's plan of care or the facility policy relative to wearing a mask for infection source control were not followed. 3. Record review of a facility policy titled, Enhanced Barrier Precautions states in part, .Everyone Must: Clean their hands, including before entering and when leaving the room . Record review revealed Resident ID #11 was admitted to the facility in October of 2023 with a diagnosis including, but not limited to, Extended Spectrum Beta Lactamase (ESBL) resistance. During a surveyor observation on 1/11/2024 at 9:08 AM, revealed Activity Aide, Staff L, entered Resident ID #11's room, an EBP room, without performing hand hygiene. Staff L was then observed touching and rubbing Resident ID #11's hand. Additionally, Staff L did not perform hand hygiene when exiting Resident ID #11's room. Furthermore, Staff L was then observed entering another resident's room, Resident ID #84, without performing hand hygiene. Record review revealed Resident ID #84 was readmitted to the facility in May of 2021 with a diagnosis including, but not limited to, resistance to Vancomycin (antibiotic). The resident's roommate, Resident ID #52, was readmitted to the facility in November of 2022 with a diagnosis including, but not limited to, resistance to Vancomycin. During a surveyor observation on 1/11/2024 at approximately 9:15 AM, revealed roommates, Resident ID #s 84 and 52, were on EBP. Additionally, Staff L was observed entering the room without performing hand hygiene, and shut the door. Furthermore, at approximately at 9:20 AM, Staff L exited the room without performing hand hygiene. During a surveyor interview on 1/11/2024 at approximately 9:20 AM with Staff L, she acknowledged that she did not perform hand hygiene when entering and exiting the above-mentioned resident's rooms and should have. During a surveyor interview on 1/12/2024 at 11:12 AM with the IP, she revealed that her expectation would be for staff to follow the precaution signs that are posted on the resident's doors to prevent the transmission of communicable diseases and infections. During a surveyor interview on 1/12/2024 at 12:27 PM with the DNS, she revealed that her expectation is for staff to wear the appropriate PPE and perform hand hygiene as indicated. Additionally, she was unable to provide evidence that the facility maintained an infection prevention and control program to help prevent the transmission of communicable diseases and infections. Record review revealed that upon surveyor exit from the facility, the facility had 5 new, positive COVID-19 cases throughout the building. 43376 47279 41720

Based on surveyor observation, staff interview and record review it has been determined that the facility failed to provide assistance devices to prevent accidents relative to the facility failing to utilize the proper mechanical lift (Mechanical lifts are devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone), the Hoyer lift, for a transfer, for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of a facility reported incident received by the Rhode Island Department of Health on 3/17/2023 states in part, On March 3, 2023, two CNAs [certified nursing assistants; NA] were assisting a resident .Into bed at approximately 10:30p.m. When they started to stand [him/her], [s/he] complained of pain to [his/her] left leg. The aides sat [him/her] back in .chair and reported the incident to the nurse. The nurse assessed the area and there was no bruising or swelling at that time .placed ice on the thigh for comfort. On 11-7 [s/he] began to complain of increased pain. An order was obtained for Tramadol [a narcotic to treat moderate to severe pain]. At 8 a.m. on 3/4/2023, the NP [nurse practitioner] gave the order to obtain x-rays of .tibia, fibula, knee, and femur. Results were all negative for acute fracture. Tramadol continued for pain as well as biofreeze and ice to .thigh .On 3/13/2023, an order for a second set of x-rays was obtained. The left hip, pelvis .were done. These x-rays showed a healing fracture of the distal femur On 3/15/23, the resident reported an increase in [his/her] pain level and was sent to [an acute care hospital] for evaluation and comprehensive imaging. [S/he] underwent imaging and was diagnosed with a femur fracture. [S/he] has been admitted for further treatment . Record review revealed the resident was admitted to the facility in May of 2013 with a diagnosis that included but was not limited to hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body), related to the resident having a CVA (cerebral vascular accident; a stroke). Record review of a Brief Interview for Mental Status Assessment was completed in February of 2023 with a score of 15/15, indicating his/her cognition was intact. Record review of a care plan last revised in February of 2023 indicated the resident was at an, increased risk of injury related to h/o [history of] CVA with right sided hemiparesis; poor trunk control and required a mechanical lift for all transfers. Record review of a Physical Therapy PT Evaluation & Plan of Treatment, dated 4/22/2022 indicates the resident is a hoyer lift for all transfers. Record review of a clinical note dated 3/3/2023 revealed the following: .cnas reported to this writer .that they attempted to transfer with EZ lift [a lift used for individuals who have the capacity to lift and support some of their weight when transferring from a seated to a standing position] from WC [wheelchair] to bed .resident reported discomfort and they sat [him/her] back in WC and came to inform this writer .instructed cnas to obtain Hoyer [type of mechanical lift used for individuals who are unable to support their weight when transferring] lift from another unit .resident hovered to bed .assessed extremities .no edema or bruising .no deformities .ice pack applied to left thigh area and elevated on pillow . Record review of clinical notes dated 3/4/2023 indicating the resident c/o [complained of] pain in left knee and posterior thigh, 8/10 pain scale on movement and s/he received scheduled Tylenol 1000mg [milligrams]. Additionally the notes indicate that the NP was notified and new orders for x-rays. Additionally, a one time order Tramadol 25 mg for pain management were given. Record review of a Radiology Results Report dated 3/4/2023 indicated the resident had arthritis in his/her knee, an old fracture of the distal femur and there were no acute fractures or dislocations noted. Additional record review of the clinical notes dated 3/5/2023 through 3/13/2023 revealed the resident continued to experience intermittent pain. Review of a physician's order dated 3/5/2023 revealed a new order for Tramadol 50 mg to be administered every 6 hours as needed for pain. Additional review of the physician orders revealed an order dated 3/13/2023 for x-rays of the left lower leg. Record review of a Radiology Results Report dated 3/13/2023 revealed an old fracture of the distal femur with impaction and the impression was a healing fracture of the distal posterior femur. Record review of a clinical note dated 3/15/2023 indicated the NP was in to see the resident who was continuing to experience increased pain in his/her left leg. Additionally the note indicated the NP reviewed the resident's x-ray results and ordered the resident to be transferred to an acute care hospital to determine if the left femur fracture was old or new. Record review of an ED Hosp-Admission Note provided by the emergency department provider dated 3/15/2023 indicated the resident had x-rays and a CT scan (X-Ray technology to produce images of the inside of the body) of his/her left knee that indicated s/he had a transversely oriented and impacted trabecular fracture [horizontal break] involving the supracondylar distal femur [thigh bone that has a break starting at the knee]. During a surveyor interview on 3/20/2023 at approximately 1:05 PM with NA, Staff A, she revealed that Resident ID #1 was a Hoyer lift and that on the day of the incident, the battery for the Hoyer lift was dead and Staff B, who was working with her on the transfer, stated let's use the, EZ Stand. She further revealed that when the resident began to bear some of his/her own weight s/he began complaining of pain. During a surveyor interview on 3/20/2023 at approximately 1:15 PM with NA, Staff B, she stated, I thought we could have lifted [him/her] with the EZ stand, [s/he] slightly began to bear weight on both legs and complained of pain during the transfer. During a surveyor interview on 3/20/2023 at approximately 1:25 PM with Registered Nurse, Staff C, she revealed that she was told by Staff A and B that they used the EZ stand to transfer Resident ID #1 and s/he complained of pain during the transfer. Additionally, she revealed that after the incident, she had instructed Staff A and B to use the Hoyer lift from another nursing unit to transfer the resident to bed. During a surveyor interview on 3/20/2023 at approximately at 2:15 pm with the Director of Nurses, she acknowledged Resident ID #1 should not have been transferred with the EZ stand lift. Additionally, she revealed that the resident has not been able to stand in seven years.

Based on record review and staff interview, it has been determined that the facility failed to ensure the medical care provided by the nurse practitioner was supervised by a physician for 1 of 8 sample residents relative to admission medication orders (ID #1). Record review revealed an Interagency Transfer form from the rehabilitation hospital dated 2/28/2019 with the following discharge order: Apixaban (Eliquis) 5mg tablet two times daily. Administration instructions ***BLACK BOX WARNING*** Avoid abrupt discontinuation of apixaban (Eliquis)in the absence of adequate alternative anticoagulation . Review of the St. Antoine Residence admission physician's orders [REDACTED]. Additionally, the residents medication orders revealed no alternative anticoagulation therapy. Resident ID# 1 was admitted to St. Antoine Residence from an inpatient rehabilitation hospital on [DATE]. The resident had been hospitalized there since 2/5/2019 following an acute inpatient hospital admission due to a [MEDICAL CONDITION] ([MEDICAL CONDITION] or stroke) with right side weakness, [MEDICAL CONDITION] (A-fib), [MEDICAL CONDITION] and dysphagia. While at the rehabilitation hospital, resident ID#1 was started on Eliquis (a blood thinner) to prevent blood clots potentially causing further [MEDICAL CONDITION]'s (strokes). Review of the Medication Administration Record [REDACTED]. Review of resident ID#1's record revealed six progress notes dated 2/28, 3/19, 3/21, 3/22, 3/25, and 3/26/2019 written by the nurse practitioner all of which indicate the patient had been taking the Eliquis medication. During a surveyor interview with the Director of Nursing on 5/13/2019 at approximately 11:30 am, she acknowledged that the Eliquis medication was not transcribed to the physician's orders [REDACTED]. Antoine Residence. During a phone interview with the Nurse Practitioner on 5/15/2019 at approximately 2:15pm she stated she thought the Eliquis medication had been transcribed to the treatment orders upon admission and that the medication had been administered to the resident twice daily. During a phone interview with the resident's primary physician on 5/15/2019 at approximately 9:20am he stated the Eliquis medication was essential to the resident's treatment and although he had signed the treatment order sheets he was unaware the resident had not been receiving the Eliquis.

Based on medical record review and staff interview it was determined the consultant pharmacist failed to identify omitted medications related to the transcription of admission orders [REDACTED]. Findings are as follows: Record review for resident ID# 1 revealed an Interagency Transfer form from the rehabilitation hospital dated 2/28/2019 with the following discharge order: Apixaban (Eliquis) 5mg tablet two times daily. Administration instructions ***BLACK BOX WARNING*** Avoid abrupt discontinuation of apixaban (Eliquis)in the absence of adequate alternative anticoagulation . Resident ID# 1 was admitted to St. Antoine Residence from an inpatient rehabilitation hospital on [DATE]. The resident had been hospitalized there since 2/5/2019 following an acute inpatient hospital admission due to a [MEDICAL CONDITION] ([MEDICAL CONDITION] or stroke) with right side weakness, [MEDICAL CONDITION] (A-fib), [MEDICAL CONDITION] and dysphagia. While at the rehabilitation hospital resident ID#1 was started on Eliquis (a blood thinner to prevent blood clots) to prevent further [MEDICAL CONDITION]'s (strokes). Review of the monthly consultant pharmacy review revealed that on 2/28/2019 the facility requested an admission medication review be completed. Attached for the pharmacist review was the hospital discharge medication list (identifying Eliquis)(a blood thinning medication) and a copy of the admission orders [REDACTED]. The consultant pharmacist failed to identify that Eliquis had not been transcribed to the physician orders [REDACTED]. Additionally, two more pharmacy reviews were completed on 3/18 and 4/7/2019, neither of which identified that the Eliquis had not been administered since admission. The Medication Administration Record, [REDACTED]. Antoine Residence staff. The resident's medication orders lacked evidence of alternative anticoagulation therapy.The Eliquis was restarted on 5/1/2019. During an interview with the Director of Nurses on 5/13/2019 at approximately 11:30 am, she was unable to provide evidence that the admission transfer orders were accurately transcribed . During a phone interview with the resident's primary care physician on 5/15/2019 at approximately 9:20am, he stated that the Eliquis medication was essential to the resident's treatment and that he had been unaware the resident had not been receiving it. During a phone interview with the consultant pharmacist on 5/15/2019 at approximately 9:40am, he stated that the pharmacist's role is to compare the interagency and the accepting facility's physician's orders [REDACTED]. He acknowledged he did not see the Eliquis listed on the interagency and consequently failed to identify the omission from active orders.

Based on record review and staff interviews, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 8 sample residents reviewed (Resident ID # 1). Findings are as follows: Anticoagulation in [MEDICAL CONDITION] Fibrillation https//www.ncbi.nlm.nih.gov/pmc/articles/PMC 91/ states in part Patients with [MEDICAL CONDITION] (AF) are at increased [MEDICAL CONDITION] risk (stroke), and they suffer more severe [MEDICAL CONDITION] with worse outcomes .Most [MEDICAL CONDITION] complications of AF are eminently preventable with oral anticoagulation .AF increases the risk of stroke five fold . Resident ID# 1 was admitted to St. Antoine Residence from an inpatient rehabilitation hospital on [DATE]. The resident had been hospitalized there since 2/5/2019 following an acute inpatient hospital admission due to a [MEDICAL CONDITION] ([MEDICAL CONDITION] or stroke) with right side weakness, [MEDICAL CONDITION] (A-fib), [MEDICAL CONDITION] and dysphagia. While at the rehabilitation hospital resident ID#1 was started on Eliquis (a blood thinner) to prevent blood clots from potentially causing additional [MEDICAL CONDITION]'s (strokes). The facility's policy titled, Transcription of Physician order [REDACTED]. Review of the Interfacility Transfer Form from the rehabilitation hospital, which was sent to St. Antoine Residence on 2/28/2019 revealed under medications for outside facility: apixaban (Eliquis) tablet 5 mg (milligrams) two times daily (a blood thinner used to treat A-fib) **BLACK BOX WARNING** avoid the abrupt discontinuation of Eliquis in the absence of adequate alternative anticoagulation . There lacked evidence that the order for Eliquis, contained on the Interfacility Transfer Form, was transcribed onto the St. Antoine's Residence physician's orders [REDACTED]. Additionally, review of the residents medication orders reveals no alternative anticoagulation therapy. Review of the progress notes written by the nurse practitioner at St. Antoine's Residence dated 2/28, 3/19, 3/21, 3/22, 3/25, and 3/26/2019 revealed documentation that this resident was actively taking Eliquis 5 mg two times daily for an irregular heartbeat. Review of a Vascular Neurology Clinic encounter form, dated 4/30/2019, revealed that the resident had been seen for a follow up appointment related to a new [DIAGNOSES REDACTED]. Notes indicated the patient started on Eliquis two weeks post stroke. It was revealed to the neurologist at this appointment that the resident ID# 1 had not been receiving the apixaban. The neurologist noted in his progress notes that ID# 1 should be on Eliquis 5 mg every 12 hours . continue Eliquis to prevent [MEDICAL CONDITION]. Don't ever stop it for a procedure or anything else without calling my office first, even if another doctor tells you to. The Medication Administration Record [REDACTED]. It was restarted on 5/1/19 after the Vascular Neurology visit on 4/30/19. During an interview with the Director of Nurses on 5/13/2019 at approximately 11:30 am, she was unable to provide evidence that the Eliquis medication had been administered to the resident between 2/28/ to 5/1/2019. During a phone interview with the resident's primary physician on 5/15/2019 at approximately 9:20am, he stated the Eliquis medication was essential to the resident's treatment and he had been unaware that the resident had not been receiving it since her admission in February.

Based on record review, resident and staff interview, it was determined that the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive care plan, and the residents' goals and preferences for 1 of 10 residents reviewed for pain management, ID #114. Findings are as follows: The facility's policy titled, Pain Evaluation, states in part, Pain interventions will be instituted by licensed nursing staff for any or all complaints or non verbal indicators of pain or as requested by the resident .Complaints of unrelieved pain are to be addressed with the resident's physician. Based off the Comparative Pain Scale, a pain level of 4 to 6 indicates moderate pain and a pain of 7 to 10 indicates severe pain. Record review for resident ID #114 reveals that he/she was admitted to the facility 11/17/2016. The resident has [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. 1.) 1/23/2017: [MEDICATION NAME] 325 mg, administer two tablets PO (by mouth) three times daily. 2.) 1/23/2017: [MEDICATION NAME] 325 mg, administer two tablets PO every 6 hours PRN (as needed) for elevated pain. 3.) 5/31/2017: [MEDICATION NAME] HYC DR 100 mg tab, administer one tablet PO daily. 4.) 1/28/2017: Evaluate and document pain on scale of 0-10 BID Review of the resident's care plan reveals a care plan for pain with interventions to report all complaints of pain and give medication as ordered (scheduled and PRN). Record review revealed a pain assessment dated [DATE] indicating that the resident's acceptable level of pain is less than 5. Review of the electronic Medication Administration Record [REDACTED] 1.) 12 times in September 2.) 30 times in August 3.) 29 times in July 4.) 34 times in June Review of the resident's progress notes during this time revealed no evidence that the resident's pain was addressed on the days in which the resident had a pain of 5 or greater. Review of the resident's physical therapy (PT) progress notes reveals the following notes: 1.) 6/9/2018: Pt (patient) has made minimal progress d/t (due to) lack of participation and neck pain when in the stand aide. 2.) 6/6/2018: Pt appeared very agitated today, reported My neck hurts so bad, they gave me pain medications and it still hurts, I can't move Pt educated on importance of participating in PT but kept refusing PT d/t neck pain. Discussed pt's current status w/ his CNA and nurse, attempted sit to stand transfer w/ stand aid but pt refused after the first trial due to c/o severe neck pain which was increasing with UE movement, pt became very agitated and refused to further participate in PT or try to stand up again. comments: I have a lot of neck pain, I can't move, leave me alone Review of the resident's record revealed that the resident's pain was documented on the eMAR as a 9 out of 10 on the pain scale on 6/6/2018 and no PRN pain medication was administered or offered. During a surveyor interview on 9/10/2018 at 12:39 PM, the resident indicated that he/she thinks that the facility could do a better job managing his pain. During a surveyor interview on 9/13/2018 at approximately 10:40 AM, the resident indicated that his/her head hurt and that it was a pain of 9 out of 10. The resident indicated that he/she thinks staff are aware. During a surveyor interview on 9/13/2018 at approximately 1:50 PM, the resident indicated that he/she has a 10 out of 10 level pain currently in his/her neck. The resident indicated that he/she told staff he/she was in pain. The resident indicated that he/she takes [MEDICATION NAME] three times a day for pain, but was unaware that he/she could receive [MEDICATION NAME] PRN. When speaking with the resident, he/she kept saying whoa and holding his/her neck and closing his/her eyes. During a surveyor interview on 9/13/2018 with the nurse, Staff A, on 9/13/2018 at approximately 2 PM, she indicated that if a resident was having pain, she would check to see if the resident could have a PRN pain medication. The nurse indicated that resident ID #114 had reported to her a pain of 8 out of 10 this morning; however, she did not check to see if he/she had a PRN pain medication available. Additionally, she indicated that she should have checked back with the resident to see if he/she was still in pain. During a surveyor phone interview with the resident's physician on 9/13/2018 at approximately 10 AM, he indicated that he/she has not been contacted by the facility recently in regard to the resident's pain. During a surveyor interview, in the presence of nurse Staff A, on 9/13/2018 at approximately 2:10 PM, the resident indicated that he/she had a pain of 10 out of 10 in his/her neck. The resident was repeating, Oh, it's awful. During a surveyor interview with the DNS on 9/13/2018 at 2:20 PM, she acknowledged that the facility was not managing the resident's pain.