Every finding on record at The Friendly Home

Based on clinical record review and staff interview, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight, for 1 of 1 resident reviewed, who experienced actual significant weight loss of 9.06% (19.4 pounds, lbs.) in two weeks, Resident ID #120.Findings are as follows:Review of a facility policy and procedure titled Weight Loss/Gain Protocol., last revised in June of 2022, states in part, .All residents are to be weighed upon admission and at least monthly; so as to monitor for weight loss or gain for underlying causes. to intervene accordingly and timely to allow for an optimal level for well-being.a significant weight discrepancy is defined as: a weight change of 3 pounds or more in one week (if resident on weekly weights); a loss/gain of 5% or greater within one month.if the reweigh is accurate and there has been significant weight loss/gain, nursing must notify the; Physician, Dietician, DNS [Director of Nurses] and Resident representative .For any resident who tolerates less than 50% of any meal, the resident(s) will be offered a nutritional supplement (the house supplement) .The nutritional supplement is not to replace a meal per say, but rather to supplement the residents' intake so they are not more at risk for weight loss.Record review revealed the resident was admitted to the facility in November of 2025 with a diagnosis including, but not limited to, kidney infection with an obstruction.Further record review revealed the s/he was recently hospitalized from [DATE]-[DATE] with a diagnosis of a deep vein thrombosis (DVT, a blood clot in a vein located deep within your body).Record review revealed the following physician's orders: 11/26/2025: Document intake each shift.12/4/2025: Daily weight for 6 days. If weight gain or loss of 3 lbs. notify the physician. 12/11/2025: Order to obtain a re-weight and if there is a 3 lbs. gain or loss to notify the physician. 12/16/2025: Daily weights for 6 days. Review of a care plan dated 12/1/2025 revealed that the resident is at nutritional risk related to malnutrition due to a mechanically altered diet, dysphagia and infection. Further review of the care plan revealed interventions to monitor weights and consult with a Registered Dietician (RD) as needed.Record review of the Registered Dietician assessment dated [DATE] revealed a readmission weight of 214.2 pounds (lbs.) and s/he was documented as a moderate nutritional risk with recommendations to monitor intake.Record review revealed the following weights were obtained from 12/3/2025 through 12/17/2025:12/3/2025: 214.2 lbs.12/4/2025: 212 lbs.12/5/2025: 211.8 lbs.12/6/2025: 212.4 lbs.12/7/2025: 212.6 lbs.12/8/2025: 200 lbs.12/11/2025: 201 lbs.12/13/2025: 201.2 lbs.12/15/2025: 202.2 lbs.12/16/2025: 195 lbs.12/17/2025: 194.8 lbs.Record review revealed the resident experienced a 9.06% (19.4 lbs.) severe weight loss in two weeks, from 12/3/2025 to 12/17/2025.Record review of the resident's intake revealed the following from 12/15 through 12/18/2025:12/15/2025-Breakfast: No intake documented-Lunch: No intake documented-Dinner: 1-25%12/16/2025:-Breakfast: No intake documented-Lunch: No intake documented-Dinner: No intake documented12/17/2025:-Breakfast: No intake documented-Lunch: No intake documented-Dinner: 1-25%12/18/2025:-Breakfast: 1-25%-Lunch: 1-25%,-Dinner: 1-25%Record review failed to reveal that the resident was offered a nutritional supplement when s/he tolerated less than 50% of their meal per the facility's policy.Record review failed to reveal evidence that the Registered Dietician (RD) or the physician was notified of the weight change of 3 pounds or more in one week per the facility's policy.During a surveyor interview on 12/18/2025 at 8:05 AM with the Director of Nursing Services (DNS), she revealed that the Nursing Assistants are to document meal intake for each meal and notify the nurse if the resident consumes less than 50%. She further revealed that the Dietician and the physician should be notified when a resident is refusing multiple meals and when a weight loss is greater than 3 lbs. for further recommendations.During a surveyor interview on 12/18/2025 at 8:19 AM with the RD, she revealed that she was unaware of the resident's weight loss since readmission. She further revealed that she was not aware that s/he was not eating most of his/her meals and would expect staff to offer a nutritional supplement and to notify the provider if less than 25%. Record review of a note authored by the Nurse Practitioner dated 12/18/2025 at 9:05 AM, states in part, .Unintended weight loss likely multifactorial due to acute infection, antibiotic use, decreased appetite, and missed meals. Poor oral intake, At risk for malnutrition. Start mirtazapine 7.5 mg [An antidepressant, commonly used as an appetite stimulant], start high-calorie/high-protein oral nutrition supplement. Nursing to document meal and supplement intake.Record review of a note authored by the RD dated 12/18/2025 at 9:15 AM, states in part, .Intake has been suboptimal, often refusing a bite or stating that [s/he] does not want it . New order for nutritional supplements twice a day and daily weights.During a surveyor interview on 12/18/2025 at 9:15 AM with the DNS, she was unable to provide evidence that the RD or the Physician were notified of the resident's severe weight loss, per the facility's policy. She further revealed that the facility notified the NP about the significant weight loss after it was brought to their attention by the surveyor and received new orders.

Based on clinical record review and staff interview the facility failed to provide care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices relative to assessment and implementation of the bowel protocol for 8 of 8 residents reviewed who required such services, Resident ID #s 2, 9, 12, 32, 66, 73, 95, and 99. Findings are as follows:Review of a facility provided policy titled, Bowel Protocol states in part, It is the policy of the facility to manage each resident's bowel function in order to promote regular, voluntary, controlled bowel evacuation of normal consistency .Further review of the policy revealed the following protocol:On Day 4 or 72 hours without bowel movement:- 7 AM - 3 PM offer prune juice as ordered.- 3 PM -11PM offer Milk of Magnesia (MOM) as ordered, if no bowel movement.- 11 PM - 7 AM offer Dulcolax Suppository as orderedOn Day 5 without a bowel movement:- 7 AM - 3 PM offer fleet enema as ordered.1. Record review revealed that Resident ID #2 was admitted to the facility in November of 2025 with a diagnosis including, but not limited to, dementia.Review of the bowel movement record revealed that s/he had no bowel movement from 12/6/2025 through 12/12/2025, 7 days and again 12/14/2025 through 12/19/2025, 6 days.Review of the physician's orders revealed the following:-120 milliliters (mL) of prune juice give once a day as needed for constipation-Milk of Magnesia suspension; 400 milligram (mg)/5 mL, administer 30 ml If no BM on day 4, per request, per nursing discretion-Dulcolax suppository 10 mg administer once a day on day 4 after no BM from MOM, per request, per nurses' discretion-Fleet Enema administer on day 5 after no BM from MOM, per request, per nurses' discretionReview of the December 2025 Medication Administration Record (MAR) revealed that the resident did not receive the prune juice, MOM, or Dulcolax suppository on 12/9/2025 or 12/17/2025, Day 4 without a documented bowel movement. Additionally, the resident did not receive a fleet enema on 12/10/2025 or 12/18/2025.2. Record review revealed that Resident ID #9 was admitted to the facility in March of 2025 with a diagnosis including, but not limited to, constipation.Review of the bowel movement record revealed that s/he had no bowel movement from 12/15/2025 through 12/19/2025, 5 days.Review of the physician's orders revealed the following:-120 milliliters (mL) of prune juice give once a day as needed for constipation-Milk of Magnesia suspension; 400 milligram (mg)/5 mL, administer 30 ml If no BM on day 4, per request, per nursing discretion-Dulcolax suppository 10 mg administer once a day on day 4 after no BM from MOM, per request, per nurses' discretion-Fleet Enema administer on day 5 after no BM from MOM, per request, per nurses' discretionReview of the December 2025 MAR revealed that the resident did not receive the prune juice, MOM, or Dulcolax suppository on 12/18/2025, Day 4 without a documented bowel movement. Additionally, the resident did not receive a fleet enema on 12/19/2025.3. Record review revealed that Resident ID #12 was admitted to the facility in July of 2022 with a diagnosis including, but not limited to, constipation.Review of the bowel movement record revealed that s/he had no bowel movement from 12/15/2025 through 12/19/2025, 5 days.Review of the physician's orders revealed the following:-120 milliliters (mL) of prune juice give once a day as needed for constipation-Milk of Magnesia suspension; 400 milligram (mg)/5 mL, administer 30 ml If no BM on day 4, per request, per nursing discretion-Dulcolax suppository 10 mg administer once a day on day 4 after no BM from MOM, per request, per nurses' discretion-Fleet Enema administer on day 5 after no BM from MOM, per request, per nurses' discretionReview of the December 2025 MAR revealed that the resident did not receive the prune juice, MOM, or Dulcolax suppository on 12/18/2025, Day 4 without a documented bowel movement. Additionally, the resident did not receive a fleet enema on 12/19/2025.4. Record review revealed that Resident ID #32 was admitted to the facility in November of 2025 with a diagnosis including, but not limited to, need for assistance with personal care.Review of the bowel movement record revealed that s/he had no bowel movement from 12/14/2025 through 12/19/2025, 6 days.Review of the physician's orders revealed the following: - 120 prune juice give once a day as needed for constipation - Milk of Magnesia suspension; 400mg/5 mL, administer 30 ml If no BM on day 4, per request, per nursing discretion - Dulcolax suppository 10 mg administer once a day on day 4 after no BM from MOM, per request, per nurses' discretion - Fleet Enema administer on day 5 after no BM from MOM, per request, per nurses' discretionReview of the December 2025 MAR revealed that the resident did not receive the prune juice, MOM, or Dulcolax suppository on 12/17/2025, Day 4 without a documented bowel movement. Additionally, the resident did not receive a fleet enema on 12/18/2025.5. Record review revealed that Resident ID #66 was admitted to the facility in October of 2018 with a diagnosis including, but not limited to, constipation.Review of the bowel movement record revealed that s/he had no bowel movement from 12/14/2025 through 12/19/2025, 6 days.Review of the physician's orders revealed the following:-120 prune juice give once a day as needed for constipation-Milk of Magnesia suspension; 400mg/5 mL, administer 30 ml If no BM on day 4, per request, per nursing discretion-Dulcolax suppository 10 mg administer once a day on day 4 after no BM from MOM, per request, per nurses' discretion-Fleet Enema administer on day 5 after no BM from MOM, per request, per nurses' discretionReview of the December 2025 MAR revealed that the resident did not receive the prune juice, MOM, or Dulcolax suppository on 12/17/2025, Day 4 without a documented bowel movement. Additionally, the resident did not receive a fleet enema on 12/18/2025.6. Record review revealed that Resident ID #73 was admitted to the facility in August of 2025 with a diagnosis including, but not limited to, need for assistance with personal care.Review of the bowel movement record revealed that s/he had no bowel movement from 12/6/2025 through 12/10/2025, 5 days and 12/12/2025 through 12/19/2025, 8 days.Review of the physician's orders revealed the following:-120 prune juice give once a day as needed for constipation-Milk of Magnesia suspension; 400mg/5 mL, administer 30 ml If no BM on day 4, per request, per nursing discretion-Dulcolax suppository 10 mg administer once a day on day 4 after no BM from MOM, per request, per nurses' discretion-Fleet Enema administer on day 5 after no BM from MOM, per request, per nurses' discretionReview of the December 2025 MAR revealed that the resident did not receive the prune juice, MOM, or Dulcolax suppository on 12/9/2025 and 12/15/2025, Day 4 without a documented bowel movement. Additionally, the resident did not receive a fleet enema on 12/10/2025 and 12/16/2025.7. Record review revealed that Resident ID #95 was admitted to the facility in December of 2023 with a diagnosis including, but not limited to, encounter for surgical aftercare following surgery on the nervous system, cranioplasty (a surgical operation on the repairing of cranial defects caused by previous injuries or operations).Review of the bowel movement record revealed that s/he had no bowel movement from 12/6/2025 through 12/12/2025, 7 days and 12/14/2025 through 12/19/2025, 6 days.Review of the physician's orders revealed the following:-120 prune juice give once a day as needed for constipation-Milk of Magnesia suspension; 400mg/5 mL, administer 30 ml If no BM on day 4, per request, per nursing discretion-Dulcolax suppository 10 mg administer once a day on day 4 after no BM from MOM, per request, per nurses' discretion-Fleet Enema administer on day 5 after no BM from MOM, per request, per nurses' discretionReview of the December 2025 MAR revealed that the resident did not receive the prune juice, MOM, or Dulcolax suppository on 12/9/2025 and 12/17/2025, Day 4 without a documented bowel movement. Additionally, the resident did not receive a fleet enema on 12/10/2025 and 12/18/2025.8. Record review revealed that Resident ID #99 was admitted to the facility in December of 2025 with a diagnosis including, but not limited to, constipation.Review of the bowel movement record revealed that s/he had no bowel movement from 11/2/2025 through 12/8/2025, 37 days and 12/13/2025 through 12/19/2025, 7 days.Review of the physician's orders revealed the following:-120 prune juice give once a day as needed for constipation-Milk of Magnesia suspension; 400mg/5 mL, administer 30 ml If no BM on day 4, per request, per nursing discretion-Dulcolax suppository 10 mg administer once a day on day 4 after no BM from MOM, per request, per nurses' discretion-Fleet Enema administer on day 5 after no BM from MOM, per request, per nurses' discretionReview of the November and December 2025 MAR revealed that the resident did not receive the prune juice, MOM, Dulcolax suppository, or a fleet enema although the resident was not documented for having a bowel movement for 37 days and 7 days.During a surveyor interview on 12/19/2025 at 9:44 AM with the Director of Nursing Services (DNS) she acknowledged that the bowel protocol was not followed for the above residents. The DNS was unable to provide evidence that the facility provided care in accordance with professional standards of practice relative to initiating the bowel protocol.

Based on clinical record review and staff interview, the facility failed to ensure that resident records are complete and accurately documented, relative to 1 of 3 residents reviewed for indwelling foley catheter (a flexible tube that is inserted into the bladder to drain urine) usage, 1 of 1 resident for Geri sleeves (a protective sleeve applied to the upper extremities) and right knee sleeve (protective sleeve for the right knee) being documented as applied and 1 of 2 residents reviewed for offloading booties usage, Resident ID #s 9, 88 and 111.Findings are as follows:1.Record review revealed Resident ID #9 was admitted to the facility in March of 2025 with diagnoses, including but not limited to, Flaccid neuropathic bladder (a condition where the bladder's muscles are unable to contract effectively, leading to urinary retention).Record review revealed that the Resident ID #9 has an indwelling foley catheter.Record review revealed a physician's order dated 3/14/2025, to change the foley drainage bag to a leg bag every morning.Surveyor observation on the following dates and times failed to reveal evidence that the indwelling foley catheter drainage bag was changed to a leg bag as ordered: - 12/16/2025 at 11:24 AM - 12/17/2025 at 10:54 AM - 12/17/2025 at 3:41 PMRecord review of the December 2025 Treatment Administration Record (TAR) revealed that the leg bag was documented on the above-mentioned dates as applied.During a surveyor interview on 12/18/2025 at 2:55 PM with Licensed Practical Nurse (LPN) Staff A, she acknowledged the resident foley drainage bag was not changed to the leg bag as ordered. Additionally, she acknowledged that it was documented as applied when it was not.2. Record review revealed Resident ID #88 was admitted to the facility in January of 2025 with diagnoses, including but not limited to, orthopedic aftercare (a time following orthopedic surgery).Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 out of 15 indicating intact cognition.Review of a care plan focus area dated 12/16/2025 revealed an alteration in skin integrity due to impaired skin integrity with an intervention for bilateral off-loading foot booties as ordered.Record review of a physician's order dated 12/15/2025 revealed the resident is to wear the booties to bilateral feet every night and off in the morning.Surveyor observation on the following dates and times failed to revealed evidence that the resident was provided the booties to bilateral feet as ordered. - 12/17/2025 at 8:36 AM - 12/18/2025 at 8:22 AM - 12/19/2025 at 8:58 AMDuring a surveyor interview on 12/19/2025 at 8:58 AM, with the resident following the observation, s/he revealed that the booties were not being applied at night.Record review of the December 2025 TAR revealed that the bilateral feet booties were documented on the above-mentioned dates as provided to the resident.During a surveyor interview on 12/19/2025 at approximately 9:00 AM with LPN, Staff C, she acknowledged that the resident bilateral feet booties were not applied as ordered. Additionally, she revealed that they were documented as being provided to the resident.3. Record review revealed Resident ID #111 was admitted to the facility in February of 2025 with a diagnosis, including but not limited to, repeated falls.Record review revealed a physician's order dated 6/20/2025 to apply Geri-sleeves to arms for all transfers. Additional review of a physician's order revealed the resident is to wear a right knee sleeve every morning and removed at bedtime.Surveyor observation on the following dates and times failed to reveal evidence that the resident was provided the Geri-sleeves as ordered or right knee sleeve as ordered:- 12/17/2025 at 10:29 AM- 12/17/2025 at 12:09 PM -12/17/2025 at 2:54 PM- 12/18/2025 at 10:20 AM - 12/18/2025 at 11:18 AMDuring a surveyor interview on 12/18/2025 at approximately 12:00 PM with LPN, Staff E, she acknowledged that the resident was not wearing the Geri-sleeve, or the right knee sleeve as ordered. Additionally, she acknowledged that the Geri sleeves and right knee sleeves were documented as applied although they was not.During a surveyor interview with the Director of Nursing Services on 12/19/2025 at approximately 1:15 PM, she was unable to explain why the residents' records were incomplete and inaccurate.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that services provided meet professional standards of quality and practices relative to 1 of 1 resident reviewed for a fall resulting in a fracture, Resident ID #32, 1 of 1 resident observed for the use of geri-sleeves (protective arm wear) during a transfer, Resident ID #111, and 1 of 1 resident reviewed for off-loading booties, Resident ID #88.Findings are as follows:1. Review of a facility reported incident submitted to the Rhode Island Department of Health on 11/24/2025 revealed that Resident ID #32 fell while ambulating to the bathroom. Additionally, it was determined that s/he fractured his/her femur (thigh bone) and was admitted to the hospital.Record review revealed Resident ID #32 was readmitted to the facility in November of 2025 with a diagnosis including, but not limited to, displaced fracture of the medial condyle of the right femur (inner part of the lower thigh bone).Review of a care plan focus area dated 9/29/2025 revealed that s/he is at risk for falls due to vertigo (dizziness) and impaired mobility.Record review of the progress notes revealed that s/he had a fall on 11/17/2025.1a. Review of a progress note dated 11/21/2025, authored by the resident's Physician, Staff F, revealed that the resident's blood pressure is low and to check orthostatic blood pressure (a type of low blood pressure that occurs when moving from a sitting to a standing position. The drop in blood pressure can result in dizziness, lightheadedness, and/or fainting. Orthostatic blood pressure measurements are recorded when an individual is lying, sitting, and standing to assess for drops in blood pressure related to positional changes).Record review failed to reveal evidence that orthostatic blood pressure monitoring was obtained on or after 11/21/2025.Record review revealed that the resident had another fall two days after the request to check orthostatic blood pressures on 11/23/2025, and was found in his/her room on the floor between the bed and bathroom. Additionally, s/he was determined to have a right femur fracture and was transported and admitted to the hospital for surgical repair of the fracture.Record review revealed that the s/he was readmitted on [DATE] following surgical repair of his/her right femur fracture.1b. Review of a document titled, Orthopaedic Surgery Discharge Instructions dated 11/25/2025 revealed that s/he was to follow up with the surgeon in 10-14 days.Record review failed to reveal evidence that a follow up appointment was made until it was brought to the facility's attention by the surveyor.During a surveyor interview on 12/17/2025 at 12:22 PM with Licensed Practical Nurse (LPN), Staff A, she acknowledged the physician's note indicating to check the resident's orthostatic blood pressure and that s/he was supposed to have a follow up appointment scheduled. She was unable to provide evidence that a follow up appointment was scheduled or that his/her orthostatic blood pressures were taken.During a surveyor interview on 12/18/2025 at 10:35 AM with the Scheduler, Staff B, she revealed that she is the person responsible for making appointments. She indicated the nursing staff will message her to make her aware of appointments that need to be scheduled. She revealed that she was unaware that the resident required a follow up appointment until staff first made her aware on 12/17/2025, after it was brought to the facility's attention by the surveyor.During a surveyor interview on 12/18/2025 at 11:20 AM with the Director of Nursing Services (DNS), she was unable to provide evidence that Resident ID #32 received services that meet professional standards of quality and practices.During a surveyor interview on 12/19/2025 at 10:40 AM with the resident's Physician, he revealed that he would expect orthostatic blood pressure monitoring to be completed within 24 hours and that his/her follow appointment would have been scheduled.2. According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.Record review revealed Resident ID #88 was admitted to the facility in January of 2025 with a diagnosis including, but not limited to, need for assistance with personal care.Review of Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 out of 15 indicating intact cognition.Review of a care plan focus area dated 12/16/2025 revealed an alteration in skin integrity due to impaired skin integrity with an intervention for bilateral off-loading foot booties as ordered.Review of a physician's order dated 12/15/2025 revealed bilateral booties to feet off in mornings and on at bedtime.Review of the December 2025 Treatment Administration Record revealed that the resident's booties were documented by the morning shift nurse as no or off, indicating that they were not applied at bedtime, as ordered, on the following dates:-12/15-12/16-12/17-12/18-12/19During a simultaneous surveyor observation and interview on 12/19/2025 at 8:58 AM with the resident, s/he was observed in bed without his/her booties in place. S/he further revealed that the staff did not apply the booties at bedtime the night prior on 12/18/2025.During an interview immediately following the above observation with LPN, Staff C, she acknowledged that the resident did not have his/her booties on.During a surveyor interview on 12/19/2025 at 9:20 AM with the Nurse Practitioner, she revealed that she would expect the staff to be following the physician's order.3. According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.Record review revealed Resident ID #111 was admitted to the facility in February of 2025 with a diagnosis including, but not limited to, atrial fibrillation (irregular hearbeat).Review of a care plan focus area dated 10/6/2025 revealed that s/he is at risk for skin breakdown with an intervention that includes to apply geri-sleeves as ordered.Review of a physician's order dated 6/20/2025 revealed to apply geri-sleeves to his/her arms and a pillow in front of his/her legs for all transfers with the stand aide transfer device.During a surveyor observation on 12/17/2025 at 11:11 AM, revealed Nursing Assistant, Staff D, transferring the resident using the stand aide transfer device without the resident wearing geri-sleeves, as ordered.During a surveyor interview immediately following the above observation with Staff D, she acknowledged the resident's geri-sleeves were not on while she was transferring the resident with the stand aide transfer device.During a surveyor interview on 12/19/2025 at approximately 10:00 AM with the DNS, she was unable to provide evidence that staff were following the physician's order.Cross reference F 842

Based on clinical record review and staff interview, the facility failed to ensure that residents who are trauma survivors, receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents experiences, and preferences, in order to eliminate, or mitigate triggers that may cause re-traumatization of the resident for 1 of 1 resident reviewed with a history of trauma, Resident ID #11.Findings are as follows:Review of an undated facility policy titled, Trauma Informed Care revealed in part, .A trauma assessment will be done on each resident by the social worker as part of the admission social history. When it is not practical or possible to interview the resident, information will be obtained from family members.when they are able and authorized to provide such information.The particular type and extent of the trauma (as best can be determined) will be incorporated when planning culturally competent, resident centered care with the purpose of avoiding re-traumatization.Record review revealed that Resident ID #11 was readmitted to the facility in October of 2024, with a diagnosis including, but not limited to, major depressive disorder severe with psychotic features.Review of a Trauma Informed Care screen dated 10/8/2024 revealed Yes was answered, indicating that the resident had experienced the following events: Natural disaster (s)(i.e. flood, tornado, hurricane, earthquake, blizzarded.Physical assault (s) i.e., hitting, pushing, pulling.Verbal Assault (s) (i.e. yelling, swearing, name calling, slur words used, threats of physical/sexual assault.Financial struggle (s) (e.g. homelessness, loss of a job with major impact, bankruptcy.Loss of (a) family member(s),friend(s), mentor(s). It was documented on the form that the resident had experienced physical and verbal abuse, lived through hurricanes, was homeless and lost a sibling. Further the screen revealed that the resident is still bothered by the events.Review of the comprehensive care plan for the resident failed to include trauma informed care and interventions to eliminate or mitigate triggers that may cause re-traumatization of the resident.During surveyor interviews on 12/18/2025 at 2:02 PM and 12/19/2025 at 9:11 AM, with the Social Worker, she acknowledged that the initial screen documents trauma and that it is not reflected in his/her care plan.During a surveyor interview on 12/19/2025 at 9:44 AM, with the Director of Nursing Services, she was unable to provide evidence of a trauma informed care plan was in place for the resident.

Based on clinical record review and staff interview, the facility failed to ensure that the irregularities identified by the Clinical Consultant Pharmacist during the Admission/readmission pharmacist Medication Regimen Review (MRR) were acted upon for 1 of 1 resident reviewed for antibiotics, Resident ID #6.Findings are as follows:Review of a facility policy titled, Medication Administration Safety Program (MASP) - Monthly Drug Regimen Review, states in part, .Any irregularities are to be documented.and reported to the resident's attending physician, the facility medical director and the director of nursing timely.The attending physician is to document in the medical record that the irregularity was reviewed, and what if any actions were taken to address it.If there is no change in the identified medication, the attending physician is to document their rationale (for not taking action) in the medical record.Record review revealed the resident was readmitted to the facility in April of 2025 with diagnoses including, but not limited to, peripheral vascular disease and osteomyelitis (bone infection) of the right ankle and foot.Record review revealed a physician's order dated 8/22/2025 for doxycycline hyclate (antibiotic) tablet, 100 milligrams, administer 1 tablet twice a day.Record review of the pharmacist's MRR, dated 8/25/2025, revealed that the continuity of care form (a document from the hospital listing discharge medications) listed the ordered doxycycline as a once-a-day medication and the facility entered the doxycycline as a twice a day medication and to clarify the order with the provider.Record review failed to reveal evidence that the admission/readmission MRR, with a noted irregularity, was reviewed and acted upon by the resident's provider.During a surveyor interview on 12/18/2025 at 1:56 PM with the Director of Nursing Services, she was unable to provide evidence that the pharmacy consultation reports were reviewed by the provider and acted upon, as required.

Based on clinical record review and staff interview, the facility failed to ensure that the resident's drug regimen is free from unnecessary drugs for 1 of 3 residents reviewed for antibiotics, Resident ID #6.Findings are as follows:Record review revealed the resident was readmitted to the facility in April of 2025 with diagnoses including, but not limited to, peripheral vascular disease and osteomyelitis (bone infection) of the right ankle and foot.Review of a Discharge Summary from an acute care hospital dated 8/22/2025, revealed an order for doxycycline hyclate (antibiotic) tablet, 100 milligrams (mg), administer 1 tablet once a day for 6 days, indicating a total number of 6 doses.Record review revealed a physician's order dated 8/22/2025 for doxycycline hyclate tablet, 100 mgs, administer 1 tablet twice a day, for a total of 12 doses.Review of the Medication Administration Record for August of 2025 revealed the resident received 13 doses of the doxycycline hyclate 100 mgs and not the 6 doses as per the discharge summary.Additional review revealed a Pharmacist's Medication Regimen Review, dated 8/25/2025, that the discharge summary listed the ordered doxycycline as a once-a-day medication and the facility entered the doxycycline as a twice a day medication and to clarify the order with the provider.Record review failed to reveal evidence that the resident's provider had ordered for the resident to receive his/her doxycycline hyclate twice a day and not the once a day as ordered. Additionally, the record failed to reveal evidence that the order was clarified after the pharmacy brought the irregularities to the facility's attention.During a surveyor interview on 12/18/2025 at 1:56 PM with the Director of Nursing Services, she acknowledged that the resident received the doxycycline hyclate for 13 doses, an additional 7 doses more than what the discharge summary indicated. Cross reference F-756 and F-881

Based on clinical record review and staff interview, the facility failed to promptly notify the ordering physician or a provider of laboratory results for 1 of 1 resident reviewed for Coumadin (an anticoagulant; a medication prescribed to thin the blood to prevent the formation of blood clots), Resident ID #84.Findings are as follows:Review of a facility policy titled, Notification of Clinicians last reviewed 1/4/2023, states in part, .The results of laboratory, radiology and other diagnostic tests will be reviewed by the unit nurse on the same day that they are received by the facility.Record review revealed the resident was admitted to the facility in March of 2025 with a diagnosis including, but not limited to, new onset of unspecified atrial fibrillation (a common type of irregular heart rhythm that may cause blood clots to form in the heart).Record review revealed the resident receives Coumadin for anticoagulation therapy.Review of a care plan focus area dated 3/19/2025 revealed that s/he receives anticoagulation therapy due to atrial fibrillation with an intervention that includes to monitor his/her prothrombin time (PT; a test that measures how quickly the blood clots and is essential for monitoring the effectiveness of anticoagulants such as Coumadin) and his/her internationalized normalized ratio (INR; another measure of how long it takes blood to clot).Record review revealed that s/he had her PT/INR bloodwork drawn on 10/8/2025 at 6:20 AM.Review of the 10/8/2025 lab document's view history revealed that the lab results were not initially reviewed until 10/9/2025 at 11:40 AM, the following day.Additional record review revealed that s/he had her PT/INR bloodwork drawn on 11/10/2025 at 6:12 AM.Review of the 11/10/2025 lab document's view history revealed that the lab results were not initially reviewed until 11/11/2025 at 4:35 PM, the following day.During a surveyor interview on 12/18/2025 at 10:01 AM with Licensed Practical Nurse, Staff A, she revealed that the PT/INR usually results between 2:00 PM and 3:00 PM the same day the bloodwork is drawn. She further revealed that she will review the bloodwork to see if the results are available between 2:00 - 3:00 PM to ensure the results are reported the provider and that the resident receives his/her Coumadin that same evening.During a surveyor interview on 12/18/2025 at approximately 11:30 AM with the Director of Nursing Services, she acknowledged the resident's PT/INR bloodwork from 10/8/2025 and 11/10/2025 were not initially reviewed until the following day and would expect staff to review them the same day.During a surveyor interview on 12/19/2025 at 10:33 AM with the resident's Physician, Staff G, he revealed that he would expect the PT/INR bloodwork to be reviewed the same day and reported immediately.Cross reference F 760

Based on clinical record review and staff interview, the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic for 2 of 3 residents reviewed for antibiotic use, Resident ID #s 6 and 33.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 . Review of an undated policy titled Antibiotic Stewardship Program, states in part, .The antibiotic stewardship program is directed toward the correct use of antibiotic- the five D's -right diagnosis, the right medication, the right dose, the right duration, and the right deceleration.1. Record review revealed Resident ID #6 was readmitted to the facility in April of 2025 with diagnoses including, but not limited to, peripheral vascular disease and osteomyelitis (bone infection) of the right ankle and foot.Review of a discharge continuity of care form from an acute care hospital dated 8/22/2025, revealed an order for doxycycline hyclate (antibiotic) tablet, 100 milligrams (mg), administer 1 tablet once a day for 6 days, indicating a total number of 6 doses.Record review for Resident ID #6 revealed a physician's order dated 8/22/2025 for doxycycline hyclate tablet, 100 mg, administer 1 tablet twice a day, for a total of 12 doses.Review of the Medication Administration Record (MAR) for August of 2025 revealed the resident received 13 doses of the doxycycline hyclate 100 mgs and not the 6 doses as per the discharge summary.Additional review revealed a pharmacist's Medication Regimen Review, dated 8/25/2025, revealed that the discharge summary listed the ordered doxycycline as a once-a-day medication and the facility entered the doxycycline as a twice a day medication, with recommendations to clarify the order with the provider.Review of the Antibiotic Timeout, completed on 8/27/2025, revealed that Resident ID #6 was prescribed doxycycline hyclate. Further review of the antibiotic timeout failed to reveal evidence that the five D's - right diagnosis, the right medication, the right dose, the right duration, and the right deceleration was observed, as the above-mentioned discrepancy was not identified.2. Record review revealed that Resident ID #33 was readmitted to the facility in December of 2025 with diagnoses including, but not limited to, sepsis and dementia.Record review revealed a physician's order for Cephalexin (antibiotic) 500 milligrams every 6 hours for 5 days due to cellulitis of his/her arm, indicating Resident ID #33 should have received 20 doses.Review of the December 2025 MAR revealed that Resident ID #33 received 17 doses of Cephalexin instead of the 20 doses that were ordered.Review of the Antibiotic Timeout, completed on 12/16/2025, revealed that Resident ID #33 was prescribed cephalexin. Further review of the antibiotic timeout failed to reveal evidence that the five D's -right diagnosis, the right medication, the right dose, the right duration, and the right deceleration was observed per the policy or CDC as the resident did not receive the 20 doses as ordered.Record review revealed that the physician was not notified about the missed doses of antibiotics until after it was brought to the facility's attention by the surveyor.During a surveyor interview on 12/18/2025 at 1:37 PM with the Director of Nursing Services (DNS) and the Regional Infection Preventionist they acknowledged that the antibiotic timeouts mention above do not include the 5 D's per the facility policy or the above-mentioned guidance per the CDC.Cross reference F-756, F-757, and F-760

Based on clinical record review and staff interview, the facility failed to ensure that all residents are free from significant medication errors for 1 of 3 residents reviewed for antibiotics relative to not receiving the ordered dosage, Resident ID #33, and 2 of 2 residents reviewed who did not receive ordered dosages of anticoagulants, Resident ID #s 46 and 84. Findings are as follows:Review of an undated policy titled, Medication Administration Safety Program (MASP) - Physician Notification states in part, It is the policy of this facility to ensure that the physician is notified when medications as ordered are not administered, regardless of circumstance.When a regularly scheduled dose of medication is not administered due to resident refusal, unavailability, resident condition or absence from the facility, the physician should be notified.1. Record review revealed that Resident ID #33 was readmitted to the facility in December of 2025 with diagnoses including, but not limited to, sepsis and dementia.Record review revealed a physician's order for Cephalexin (antibiotic) 500 milligrams (mg) every 6 hours for 5 days due to cellulitis (skin infection) of his/her arm, indicating Resident ID #33 should have received 20 doses.Review of the December 2025 Medication Administration Record (MAR) revealed that Resident ID #33 received 17 doses of Cephalexin instead of the 20 doses that were ordered.During a surveyor interview on 12/18/2025 at 10:19 AM with the Director of Nursing Services (DNS) and the Regional Infection Preventionist, they acknowledged that Resident ID #33 did not receive the ordered dosage of antibiotics.Record review revealed that the physician was not notified about the missed doses of antibiotics until after it was brought to the facility's attention by the surveyor.2. Record review revealed that Resident ID #46 was admitted to the facility in November of 2025 with diagnoses including, but not limited to, dementia and schizophrenia.Record review revealed a physician's order for Eliquis (anticoagulant; a medication prescribed to thin the blood to prevent the formation of blood clots) 2.5 mg twice daily.Review of the November and December 2025 MAR revealed that Resident ID #46 did not receive his/her ordered dose of Eliquis on 11/25, 11/26, 12/6 and 12/17/2025 due to refusal.Record review failed to reveal evidence that the Physician was made aware of the resident's refusal of Eliquis.During a surveyor interview on 12/19/2025 at 10:55 AM with Physician, Staff F, he revealed that he was unaware the resident refused his/her Eliquis and would expect the resident to get his/her medication as ordered.During a surveyor interview on 12/19/2025 at 11:11 AM with the DNS she acknowledged that Resident ID #46 did not receive his/her ordered dosage of Eliquis on the above noted dates.3. Record review revealed that Resident ID #84 was admitted to the facility in March of 2025 with diagnoses including, but not limited to, heart failure and atrial fibrillation (abnormal heart rhythm).Record review revealed a physician's order dated 9/10/2025 through 10/7/2025 for Warfarin (anticoagulant) 2 mg to be administered on Sunday, Tuesday, Wednesday, Saturday and Friday in the evening.Further record review revealed a physician's order to obtain labs on 10/8/2025 to determine continued dosing of Warfarin.Review of the Coagulation Lab dated 10/8/2025 revealed the results were reported to the Doctor with new orders to continue with Warfarin 2 mg on Sunday, Tuesday, Wednesday, Saturday and Friday in the evening.Review of the October 2025 MAR revealed Resident ID #84 did not receive the ordered dosage of Warfarin on 10/8/2025.Record review revealed a physician's order dated 10/27/2025 through 11/9/2025 for Warfarin 1.5 mg every evening.Further record review revealed a physician's order to obtain labs on 11/10/2025 to determine continued dosing of Warfarin.Review of the Coagulation Lab dated 11/10/2025 revealed the results were reported to the Physician with new orders to continue with Warfarin 1.5 mg every evening.Review of the November 2025 MAR revealed Resident ID #84 did not receive the ordered dosage of Warfarin on 11/10/2025.Record review revealed a physician's order dated 11/24/2025 through 12/7/2025 for Warfarin 1.5 mg every evening.Further record review revealed a physician's order to obtain labs on 12/8/2025 to determine continued dosing of Warfarin.Review of the Coagulation Lab dated 12/8/2025 revealed the results were reported to the Physician with new orders to continue with Warfarin 1.5 mg every evening.Review of the December 2025 MAR revealed that Resident ID #84 did not receive the ordered dosage of Warfarin on 12/8/2025.During a surveyor interview on 12/18/2025 at 11:30 AM with the DNS she acknowledged that Resident ID #84 was not administered Warfarin on 10/8, 11/10 and 12/8/2025 as ordered. Additionally, the DNS was unable to provide evidence that Resident ID #s 33, 46 and 84 were kept free from significant medication errors.

Based on surveyor observation, clinical record review and staff interview, the facility failed to ensure that each resident receives and is provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being, for 1 of 1 resident admitted with a diagnosis of schizophrenia, Resident ID #46.Findings are as follows:Record review revealed the resident was admitted to the facility in November of 2025 with diagnoses including, but not limited to, dementia with behavioral disturbances and schizophrenia (a mental illness that affect how people think and behave).Review of the resident's care plan revealed a focus area initiated on 11/26/2025, for the use of psychotropic medications related to his/her diagnosis of schizophrenia and yelling out nonsensical dialogue. Interventions include, but are not limited to, administer anti-psychotic medication as ordered and monitor its side effects.Review of a Minimum Data Set assessment dated [DATE] section E for behavioral symptoms revealed that the resident significantly intrudes on the privacy or activity of other residents.Record review of a physician's order dated 11/20/2025 revealed Fluphenazine (a medication used to treat psychotic disorders such as schizophrenia) 5 milligrams (MG) to be administered every 8 hours as needed for severe agitation related to the diagnosis of Schizophrenia.Review of the Medication Administration Record (MAR) for the months of November and December 2025 revealed the above-mentioned medication was administered once for a behavior issue on 11/26/2025 at 10:17 PM. Additionally, the MAR indicated the medication administration follow-up as effective. Further review of the MAR revealed the medication was discontinued on 12/2/2025.Review of the nursing progress note dated 11/26/2025 revealed that the resident was yelling out most of the night, calling imaginary people. Additional review of the progress note revealed that the as needed (PRN) Fluphenazine was administered to the resident with a positive result. During surveyor observations on the following dates and times revealed the resident to be behavioral: 12/16/2025 at 10:30 AM, the resident was observed in a recliner in the common area, yelling out loud incoherent words. At this time other residents were observed to be upset by this behavior and were observed yelling back at him/her, asking him/her to keep quiet. 12/16/2025 at 12:03 PM, the resident was observed being taken to the main dining room for lunch along with other residents. Approximately 5 minutes later Licensed Practical Nurse (LPN) Staff E was observed rushing to the main dining room remove the resident to prevent him/her from disturbing the other residents when [s/he] yells out. 12/16/2025 at 1:10 PM, the resident was observed in the common area yelling out. 12/17/2025 at 10:26 AM, the resident was yelling out jumbled words. 12/17/2025 at 1:36 PM, the resident was observed in the recliner yelling, appeared to be calling someone in incoherent words which apparently was upsetting other residents who were present. 12/17/2025 at 2:50 PM, the resident was observed yelling out in the hallway.Record review failed to reveal evidence of a professional Psychiatric consultation for the resident despite his/her diagnosis of schizophrenia.During a surveyor interview on 12/17/2025 at 2:29 PM with LPN Staff C, she acknowledged the resident's yelling is frequent then stated that it is his/her baseline. Additionally, the nurse was unable to provide evidence of a Psychiatric consultation for the resident.During a surveyor interview on 12/18/2025 at 8:50 AM with Staff E, she revealed that the resident came from another facility. Additionally, Staff E revealed the resident yells out all day however, s/he does not have a PRN medication to provide him/her because the last one was discontinued on 12/2/2025. Further, Staff E indicated that the yelling out upsets other residents who yell back at the resident. During a surveyor interview on 12/18/2025 at 9:06 AM with the Director of Nursing Services, she revealed the resident has a diagnosis of Schizophrenia and Dementia but has no current PRN medication. Additionally, she indicated that the PRN Fluphenazine was discontinued on 12/2/2025 for not being utilized in the 14 days period. Further, she acknowledged the facility has not requested a psychiatric consult for the resident even though s/he needs one as well as the PRN medication related to the behaviors.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to provide appropriate treatment and services for residents with a foley catheter (a flexible plastic tube inserted into your bladder) for 1 of 3 residents reviewed, Resident ID #9.Findings are as follows:Record review revealed that the resident was admitted to the facility in March of 2025 with a diagnosis including, but not limited to, flaccid neuropathic bladder (a condition that results in the inability to effectively empty the bladder due to nerve damage).According to Lippincott Nursing Procedures, 9th Edition, pages 432-33 states in part, Catheter care .Keep the drainage bag below the level of the patient's bladder to prevent backflow of urine into the bladder, which increases the risk of CAUTI [A catheter-associated urinary tract infection caused by germs entering the urinary tract through a catheter].Review of a care plan focus area dated 3/14/2025 revealed a focus area for a foley catheter with an intervention to maintain the foley below bladder level.During multiple surveyor observations, the resident was observed seated in his/her recliner with his/her foley catheter tubing extending upwards over the arm rest of the recliner and into the drainage bag, and not below bladder level, on the following dates and times:-12/16/2025 at 11:24 AM-12/17/2025 at 10:54 AM and 3:41 PM-12/18/2025 at 2:55 PMDuring a surveyor interview immediately following the above observation on 12/18/2025 with Licensed Practical Nurse, Staff A, she acknowledged the resident's foley catheter tubing extended upwards over his/her recliner's armrest, and was not below bladder level, and revealed that it should be.During a surveyor interview on 12/18/2025 at 3:15 PM with the Director of Nursing Services, she revealed that she would expect staff to maintain the foley catheter tubing below the resident's bladder level.Cross reference F 842

Based on record review and staff interview it has been determined that the facility failed to ensure that a resident received adequate supervision for 1 of 1 resident reviewed who was able to successfully elope from the facility, Resident ID #1.Findings are as follows:Review of a facility reported incident submitted to the Rhode Island Department of Health on 8/1/2025 revealed that Resident ID #1 left the faciity on 7/31/2025 and was seen by a neighbor, who subsequently notified the local police department. The report further revealed that the resident was transported back to the facility by the police.Record review of a facility policy titled, Elopement assessments states in part, .It is the policy of this facility to maintain a safe and secure environment for all our residents. In order to achieve this; residents who are at risk for wandering/elopement need to be identified and a care plan developed to eliminate risk.An assessment is also to be completed whenever the resident exhibits change in behaviors which is a signal a change in the risk, such as. wandering with intent to leave, wandering unsafely, actually attempting to leave the building, etc.Record review revealed that Resident ID #1 was admitted to the facility in April 2025, with diagnoses to include, but are not limited to, traumatic brain injury, status post craniectomy (surgical procedure involving the temporary removal of a portion of the skull), and aphasia (a language disorder that affects a person's ability to communicate).Review of the Minimum Data Set assessment dated [DATE] revealed that the resident has moderately impaired cognition, poor decision-making abilities, and requires supervision and cueing. Record review of a physician's order dated 4/9/2025, revealed that the resident is to wear a helmet at all times, due to post-craniectomy.Record review of a progress note dated 7/17/2025, marked as a Recorded as Late Entry on 07/21/2025 10:37 states in part, [Resident] was seen outside by this writer, noted [s/he] had [his/her] helmet off and did not have [his/her] wheelchair, wheelchair was noted to be in the lobby of the facility.Unit staff was made aware [resident] was outside and needs to have someone with.when outside, staff came to lobby and retrieved.w/c and got [resident] from outside and brought [resident] in. [Resident] was again visually upset and made aware when staff have time they can bring [him/her] out but can't go out alone.Record review failed to reveal evidence that an elopement assessment or risk evaluation was completed following the 7/17/2025 incident.Record review of a Physical Therapy document dated 7/18/2025 revealed that the resident has a traumatic brain injury, craniectomy and is to wear a helmet when out of bed. The resident was referred to physical therapy to reassess functional mobility as the patient is often found walking alone in the facility. Additionally, the report revealed that the resident was discharged from physical therapy on 7/31/2025 and indicated that the staff and resident were educated that s/he cannot go outside on their own. Record review of a progress note dated 7/31/2025 revealed that at 6:55 PM, a call was received by the local police department that a resident was found wandering over one mile from the facility. The resident was returned to the facility by the police and assessed by staff. The provider was updated, and the resident was sent to the emergency room for an evaluation.Record review of the police log dated 7/31/2025 revealed a call to 911 was made at 6:43 PM, requesting a well-being check on a confused person in the area. An officer approached the person and asked if they needed help. The person mumbled incoherently and continued down the road. At approximately 7:03 PM the person was identified as Resident ID #1, and the facility was contacted and confirmed that the resident was missing from the facility. Additionally, the report revealed that at 7:22 PM the resident was escorted back to the facility by police. Review of a hospital document dated 7/31/2025 revealed Resident ID #1 presented to the emergency room for medical clearance. The report states in part, .patient is aphasic at baseline.Per report, patient eloped for [approximately] 2 hours before the facility was aware of the elopement, now requesting medical clearance.Record review of a facility provided document titled, [Resident ID #1] Timeline, revealed that a Nursing Assistant last recalled seeing the resident at approximately 5:45 PM. At 6:58 PM the facility was called and made aware that the local police department had found the resident approximately 1.5 miles from the facility after a neighbor found the resident walking.During a surveyor interview on 8/5/2025 at 11:29 AM, with Certified Medication Technician, Staff A, she revealed that she was working on 7/31/2025 and at approximately 4:55 PM, she delivered the resident his/her medications in his/her room. She further revealed that this was the last time she had seen the resident and at approximately 7:30 PM, she was told by another staff member that the local police had called and found the resident and would be bringing him/her back to the facility.Surveyor observations of the facility's surveillance camera footage on 8/5/2025 at approximately 1:30 PM, in the presence of the Director of Nursing Services, confirmed that on 7/31/2025 the resident had exited the front door of the facility alone, without his/her helmet at 5:49 PM. Further review revealed s/he walked away from the facility property.During a surveyor interview on 8/5/2025 at 12:36 PM with the Administrator, she acknowledged that the facility was not aware that Resident ID #1 had left the faciity on 7/31/2025 until the police called to notify them approximately 1.5 hours after s/he left the facility. The facility's failure to implement interventions for a resident with a known cognitive impairment and to follow their policy relative to wandering unsafely and actually attempting to leave the building placed a cognitively impaired resident at risk for more than minimal harm, injury, impairment, or death. These failures resulted in this resident exiting the facility unsupervised and being found approximately 1.5 miles away from the facility without his/her ordered helmet.

Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided by the facility meet professional standards of quality relative to following physician's orders for 1 of 4 residents reviewed, Resident ID #1. Findings are as follows: 1a. Record review of a community reported complaint submitted to the Rhode Island Department of Health on 5/20/2025 alleges that Resident ID #1 was prescribed a pain patch from the hospital to be given to Resident ID #1 on 5/15/2025 and it wasn't administered to him/her until 5/16/2025 at 8:00 PM. According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review revealed Resident ID #1 was readmitted to the facility in May of 2025 with diagnoses including, but not limited to, spinal fusion and orthopedic aftercare. Record review revealed a physician's order dated 5/15/2025, to administer Buprenorphine patch (a medication prescribed to treat pain) 5 micrograms (mcg) per hour; apply patch once a week on Thursday. Record review of the May 2025 Medication Administration Record (MAR) revealed that the Buprenorphine was signed off as administered as ordered on 5/15/2025. During a surveyor interview on 5/22/2025 at 11:01 AM with the Unit Manager, Registered Nurse, Staff A, she indicated that the Buprenorphine patch was not available in the facility on 5/15/2025 for administration to the resident, although it was signed off as administered by Registered Nurse, Staff B. Record review of an interview provided by the facility, dated 5/16/2025 with Registered Nurse, Staff B, she acknowledged she signed off the Buprenorphine patch as administered to the resident although it was not. 1b. Record review revealed a physician's order dated 5/20/2025, to administer Dilaudid (a medication prescribed to treat pain) 4 milligrams (mg) by mouth every six hours as needed for pain. Record review of the May 2025 Medication Administration Record (MAR) revealed that the Dilaudid was signed off as administered on 5/21/2025 at 12:16 PM. Record review of the Narcotic book revealed the resident received Dilaudid 2 mg on the following dates and times and not the 4 mg, as ordered: -5/21/2025 at 11:45 AM -5/22/2025 at 11:00 AM During a surveyor interview on 5/22/2025 at approximately 12:15 PM with Licensed Practical Nurse, Staff C, she acknowledged that she administered 2 mg of Dilaudid to the resident on 5/21/2025 and 5/22/2025 instead of the 4 mg, as ordered. During a surveyor interview on 5/22/2025 at approximately 2:10 PM with the Director of Nursing Services, he acknowledged that Resident ID #1 did not receive his/her Buprenorphine as ordered on 5/15/2025. Additionally, he indicated that it would be his expectation for the resident to have received his/her Buprenorphine and Dilaudid per the physician's order.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store drugs and biologicals in accordance with currently accepted professional principles relative to 1 of 1 unit observed. Findings are as follows: Record review of a facility policy titled, Ordering and Receiving Controlled Medications dated January 2023 states in part, .Only authorized, licensed nursing and pharmacy personnel have access to controlled medications . Record review of a facility policy titled, Controlled Medication Storage dated January 2025 states in part, .A controlled medication accountability record is prepared when receiving inventory if any controlled substance to establish a record of receipt and disposition in sufficient detail to enable accurate reconciliation. The following information is completed: .Name of resident .Prescription number .Name, strength (if designated), and dosage form of medication .date received .quantity received .name of person receiving medication . Review of a facility reported incident submitted to the Rhode Island Department of Health on 3/27/2025 indicated that on 3/25/2025 narcotic patches were delivered to the facility but were not able to be located. The report further alleges that the nurse had no recollection of receiving the medication from the pharmacy. Record review revealed Resident ID #1 was admitted to the facility in February of 2025 with diagnoses including, but not limited to, a chronic inguinal (groin) wound and pain to the left hip. Record review revealed a physician order for Buprenorphine patch (a controlled opioid medication used to treat substance use disorder and pain) 10 micrograms (mcg) once every Tuesday. Review of a pharmacy shipping manifest revealed four Buprenorphine 10 mcg patches were delivered to the facility on [DATE] and signed by Nursing Assistant (NA), Staff A. Review of the controlled substance count book failed to reveal evidence that the Buprenorphine had been received and added to the count. During a surveyor interview on 3/31/2025 at 10:56 AM with Staff A, he indicated that he signed for the controlled medication on 3/25/2025 and should not have. During a surveyor interview on 3/31/2025 at 11:06 AM with Registered Nurse, Staff B, she indicated that she was the nurse on the unit on 3/25/2025 and does not recall receiving any medications from the pharmacy. She further indicated that NAs should not sign and receive medications from the pharmacy. During a surveyor interview on 3/31/2025 at approximately 12:30 PM with the Director of Nursing Services, he acknowledged that the NA signed that he received the Buprenorphine and should not have. He further acknowledged that the controlled medication had not been documented as received into the narcotic book as outlined in the facility policy.

Based on record review, and staff interview, it has been determined that the facility failed to provide treatment and care in accordance with professional standards of practice and failed to follow physician orders relative to administering an as needed blood pressure medication with parameters for 1 of 1 resident reviewed, Resident ID #1 and 1 of 1 resident reviewed for the use of senna plus (two laxatives combined used to treat occasional constipation), Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health, on 12/23/2024 alleges that the resident was receiving senna plus while having diarrhea, dehydration and an active diagnosis of clostridioides difficile (C. diff-a bacterium that causes an infection of the colon causing diarrhea and dehydration). Additionally, the resident representative had multiple concerns relative to the care that the resident received while at the facility and removed him/her from their care. During a surveyor interview on 12/30/2024 at 8:53 AM, with the complainant, s/he revealed that the resident was receiving unnecessary medications for his/her blood pressure and stated, [S/he] was being harmed by the facility administering a laxative while [s/he] was dehydrated and having diarrhea. A. According to Mosby's 4th Edition, Fundamentals of Nursing page 314, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review revealed that Resident ID #1 was admitted to the facility in September of 2024 with diagnoses including, but not limited to, hypertension (high blood pressure) and adult failure to thrive. Record review revealed a physician's order dated 9/16/2024 for Hydralazine (a medication prescribed to regulate blood pressure) administer 25 milligrams (mg) three times per day as needed for systolic blood pressure (pressure in your arteries when your heart beats) above 145. Review of the September and October 2024 Medication Administration Records (MAR) revealed that the resident was administered the Hydralazine when the resident's SBP indicated it should be held based on the parameters on the following dates and times: -9/14/2024 133/75 HS (At bedtime) -9/15/2024 112/78 HS -9/18/2024 134/78 Early AM -9/18/2024 132/58 Early PM -9/23/2024 122/76 HS -9/24/2024 140/54 HS -9/26/2024 128/70 Early PM -9/26/2024 130/46 HS -9/27/2024 142/79 Early AM -9/28/2024 126/60 Early AM -9/28/2024 116/51 HS -9/29/2024 123/59 Early AM -10/2/2024 129/76 HS -10/3/2024 122/68 HS During a surveyor interview on 12/30/2024 at 12:23 PM via the telephone with the facility's Nurse Practitioner, she revealed that she was unaware that the staff were administering the Hydralazine outside of the parameters ordered. Additionally, she revealed that she would expect staff to follow the order as written. During a surveyor interview on 12/30/2024 at 12:51 PM with the Assistant Director Nursing Services, she was unable to provide evidence that the facility staff followed the physician order for Hydralazine. B. Record review revealed a nursing progress note dated 10/21/2024 at 9:47 AM which revealed that the resident's representative called to report that the resident had several loose stools. The note further revealed that this was reported to the Nurse Practitioner. Record review of a nursing progress note dated 10/21/2024 at 1:34 PM revealed that the resident's representative was updated of a new physician's order to test Resident ID #1's stool for C. diff. Record review of a laboratory testing document titled, Microbiology dated 10/22/2024 revealed a positive test result for C. diff. Additionally, there was a new physician's order for Vancomycin 250 mg (an antibiotic) every 6 hours for 10 days and 1 packet of Banatrol (a soluble fiber and a prebiotic which is used to solidify the stool) twice a day. Record review revealed a nursing progress note dated 11/9/2024 at 5:04 PM which revealed that the resident was warm to the touch and lethargic. His/her temperature was 100.4 degrees Fahrenheit. Additionally, Tylenol was administered and a new order was obtained from the physician to start a clysis (an infusion of fluid) and give 1 liter of normal saline. Record review revealed a physician order with a start date of 9/17/2024, for Senna Plus. Review of the October and November 1st through 11th 2024 Medication Administration Records (MAR) revealed that the resident was administered the Senna Plus daily from 9/17/2024 through 11/10/2024, while the resident was experiencing diarrhea and was being treated for C. diff. During a surveyor interview on 12/30/2024 at 12:23 PM with the APRN, she stated, Senna Plus should absolutely not be administered while a resident has C. diff. She further revealed that she was unaware that s/he was receiving this medication and would have expected it to be held and reported to her as a nursing measure to prevent harm to the resident. During a surveyor interview on 12/30/2024 at 12:49 PM with the Assistant Director of Nursing, she confirmed that the Senna Plus was given with an active diagnosis of C. diff and while the resident was experiencing diarrhea.

Based on record review, staff and resident representative interview, it has been determined that the facility failed to notify the resident representative(s) when there is need to alter treatment significantly for 1 of 2 residents reviewed, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health, on 12/23/2024 alleges that the resident was started on several medications, had a foley catheter (a device that drains urine from your urinary bladder into a collection bag outside of your body) inserted and the facility failed to notify the resident's representative regarding these changes in the residents medical status. Additionally, the complainant had multiple concerns relative to the care that the resident received while at the facility and removed the resident from their care. A. Record review revealed Resident ID #1 was admitted to the facility in September of 2024 with diagnoses including, but are not limited to, dementia and cognitive communication deficit. Review of an admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating s/he has moderately impaired cognition. The resident was discharged in November of 2024. Record review of the resident's medical record revealed that the resident had a medical power of attorney (a legal document that appoints someone as their representative and gives that person the power to act on their behalf). Record review of a facility policy titled, Resident Change in Condition dated 10/17/2023, states in part, .The facility will ensure that resident changes in condition are identified timely, reported to the Physician (and Representative when applicable), and documented in the medical record timely .changes in condition include but may not be limited to .change in vital signs . Record review revealed a nursing progress note dated 9/14/2024 at 9:17 AM which revealed that the resident had an elevated blood pressure on admission. It further revealed a new physician's order to give hydralazine (a medication to treat high blood pressure) 25 milligrams (mg) every shift for blood pressures over 145. Additional record review failed to reveal evidence that the resident's representative was notified of these changes in the resident's medical status. B. Record review revealed a nursing progress note dated 9/20/2024 at 4:44 PM, which revealed a new physician's order to give losartan (a medication to treat high blood pressure) 25 mg daily. Additional record review failed to reveal evidence that the resident's representative was notified of this change. C. Record review revealed a nursing progress note dated 9/23/2024 at 8:55 PM which revealed a new diagnosis of prostatitis (a disorder of the prostate gland usually associated with inflammation). Additionally, it revealed new physician orders to start Ciprofloxacin (antibiotic) for 10 days and start vitamin b 12 injections twice a week for 4 weeks. Additional record review failed to reveal evidence that the resident's representative was notified of these changes. D. Record review revealed a nursing progress note dated 10/7/2024 at 7:00 PM which revealed the resident was seen by the facility's Nurse Practitioner (APRN) with new orders to insert a foley catheter, schedule a urology consult and start finasteride (a medication given for an enlarged prostate) 5 mg daily. Additional record review failed to reveal evidence that the resident's representative was notified of these changes. During a surveyor interview on 12/30/2024 at 8:53 AM, with the resident's representative, s/he revealed that the facility failed to call or update on the above physician's orders. S/he further revealed s/he would have not agreed with the foley being inserted and made several requests for that to be removed. The representative indicated that s/he was in the facility frequently and felt that these changes could have been easily communicated to him/her while s/he was there. During a surveyor interview on 12/30/2024 at 11:26 AM, with Licensed Practical Nurse, Staff A, she revealed that it is the facility's policy to notify the resident's representative if there is a change in the resident's medical status or if there are new orders when the resident is cognitively impaired. During a surveyor interview on 12/30/2024 at 12:23 PM with the APRN, she revealed that the facility was responsible for updating the resident's representative with all new orders or changes in the residents condition. She further revealed that on occasion while assessing the resident there would be family or friends at the bedside, but she was unaware who his/her medical power of attorney was during that time. During a surveyor interview on 12/30/2024 at 12:49 PM, with the Assistant Director of Nursing, she was unable to provide evidence the residents representative was notified of the above changes in his/her medical status. Cross reference F 684

50004 21613 Based on record review and staff interview, it has been determined that the facility failed to document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies which must be reviewed and updated as necessary, and at least annually. Additionally, the facility failed to review and update the 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: Review of a facility provided document titled, Facility assessment dated [DATE] failed to reveal the following components as required: - The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population - The staff competencies that are necessary to provide the level and types of care needed for the resident population - The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population - Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services Further review of the document titled Facility Assessment, failed to reveal evidence of the facility's resources, which include but are not limited to: - Equipment (medical and non- medical) - Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies - All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care - Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and . During a surveyor interview on 10/2/2024 at 3:33 PM with the Administrator, she acknowledged that the facility assessment failed to address the required components. Cross reference: F 684, F 694, F726, and F 880.

Based on record review and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate competencies and skills sets to provide nursing and related services to assure resident safety to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment as required. Findings are as follows: Record review failed to reveal evidence that competencies and skills sets for wound vacuum-assisted closure (Wound VAC- a technique that uses negative pressure to pull the edges of a wound together and promote healing) device, peripherally inserted central catheter (PICC line, long, flexible tube that's inserted into a vein in the arm and threaded into a large vein near the heart, used to deliver medication or other treatments), and intravenous (IV) medication administration were completed for the following licensed nurses prior to it being brought to the attention of the facility by the surveyor on 9/30/2024: - Registered Nurse (RN), Staff G with a hire date of 4/19/2022 - RN, Staff C with a hire date of 10/5/2021 - Licensed Practical Nurse (LPN), Staff H with a hire date of 9/5/2023 - LPN, Staff F with a hire date of 12/18/2023 During a surveyor interview on 10/2/2024 at 11:24 AM with the Staff Development Coordinator, she was unable to provide evidence that competencies and skill sets relative to wound VAC care, PICC line dressings changes and intravenous medication administration were provided to license nurses prior to providing care. During a surveyor interview on 10/2/2024 at 12:44 PM with the Director of Nursing Services, he was unable to provide evidence that above mentioned education and competencies were completed prior to providing care. Cross reference: F684, F694, F726, and F880. 47939

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 and 2 of 2 unit dining rooms. Findings are as follows: 1. The Rhode Island Food Code 2018 Edition 3.501.16, states in part, Time/Temperature Control for Safety Food Hot and Cold Holding .shall be maintained at .5 degrees C [Centigrade, which is 41 degrees Fahrenheit] or less . During a surveyor observation on 10/1/2024 at approximately 12:00 PM of the lunch meal service on the North unit, revealed turkey sandwiches had a cold holding temperature of 60 degrees F and chef's salads had a cold holding temperature of 59 degrees F. During a surveyor interview with the Food Service Director (FSD) immediately following the above mentioned observations, she acknowledged the food's were not within the acceptable cold holding temperature range. 2. The Rhode Island Food Code 2018 Edition 2-402.11, states in part, .food employees shall wear hair restraints, beard restraints that are designed and worn to effectively keep their hair from contacting exposed food . During a surveyor observation of the main kitchen on 9/30/2024 at approximately 9:30 AM, Dietary Aide, Staff I was observed with full facial hair and not wearing a beard restraint while assisting in dessert set up. During a surveyor observation on 10/1/2024 at approximately 12:30 PM, Staff I was observed assisting in serving beverages to residents in the North unit dining room without wearing a beard restraint. An additional surveyor observation on 10/2/2024 at approximately 12:00 PM, Staff I was observed assisting in serving beverages to residents in the [NAME] dining room without wearing a beard restraint. During a surveyor interview on 10/3/2024 at approximately 11:10 AM with the FSD, she acknowledged that Staff I was not wearing a beard restraint as required. 3. The Rhode Island Food Code 6.403.11 2018 Edition states in part, .because employees could introduce pathogens to food .areas designated to accommodate employees' personal needs must be carefully located . During a surveyor observation on 10/3/2024 at 12:30 PM in the main kitchen, a reach in refrigerator that stored desserts for residents revealed staff lunches were stored in the same refrigerator on the bottom shelf. During a surveyor interview with the FSD immediately following the above mentioned observation, she acknowledged that staff lunches should not be stored with facility purchased foods for residents.

Based on record review and staff interview it has been determined that the facility failed to be administered in a manner that enables it to use its' resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident relative to ensuring that its' Nursing Assistants (NA) are licensed. Findings are as follows: Record review revealed Resident ID #1 was admitted to the facility in November of 2023 with diagnoses including, but not limited to; fusion of spine lumbar region (surgery of lower spine), wedge compression fracture of the third lumbar vertebra (a fracture of the front of the lower part of the spine), and weakness. Record review of the physical therapy (PT) evaluation and plan of treatment dated 11/22/2023 revealed .Precautions: *TLSO [Thoracic Lumbar Sacral Orthotic- back brace] for 1 more week as of 11/22/23 .Transfers .2 assist x FWW [Front Wheeled Walker] with TLSO on when out of bed .transfers with gait belt . Record review revealed on 11/23/2023, the resident sustained a fall while transferring with the assistance of one unlicensed Nursing Assistant, Staff A, from the bathroom in his/her room. Further review revealed Staff A did not utilize a gait belt and the resident was not wearing a back brace during the transfer and at the time of the fall. Record review revealed the resident experienced an increase in pain following the fall and had a decline in functional status. Record review revealed Staff A, the NA involved in the transfer of the resident, graduated from the facility's NA program on 10/23/2023, had not received his State of Rhode Island Temporary NA license and should not have been providing care independently to residents in the facility. Review of the daily working schedule from 10/25/2023 through 11/27/2023 revealed Staff A worked independently as an NA for a total of 26 days while not actively licensed as a NA. Further record review revealed 1 additional NA, Staff F graduated from the facility's NA program on 10/23/2023, had not received her State of Rhode Island Temporary NA license and should not have been providing care independently to residents in the facility. Review of the daily working schedule from 10/25/2023 through 11/27/2023 revealed Staff F worked independently as an NA for a total of 18 days while not actively licensed as a NA. During a surveyor interview on 11/29/2023 at 10:42 AM with Licensed Practical Nurse who is also the Staff Development Coordinator, Staff G, she indicated that she completes the required competencies with the staff members who are in the facility's NA training program. She further indicated that she would expect the NA to have received his/her temporary NA license prior to providing resident care independently. Additionally, she indicated that she would expect a staff member who has not yet received their temporary NA license to work only under direct supervision of a licensed staff member. During a surveyor interview on 11/29/2023 at 11:04 AM with the scheduler, Staff H, she indicated that it is the facility's practice to put the graduates of the facility's NA program on the schedule when they complete their classes and competencies. She further indicated that she is told by other staff members when the NA trainees should be scheduled to provide care to the residents as an NA independently. During a surveyor interview on 11/29/2023 at approximately 1:50 PM with the Administrator, she indicated that once a student completes the facility's training program, they are then scheduled to work on the floor to provide resident care independently while they wait for their temporary license to be issued by the Rhode Island Department of Health. She further indicated that this is how the program has been run for [AGE] years. Additionally, she was unable to provide evidence that the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident receives adequate supervision and assistive devices to prevent an accident for 1 of 1 resident reviewed who experienced an actual fall, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 11/27/2023 revealed Resident ID #1 sustained a fall at the facility while being transferred by an unlicensed staff member. Additionally, the complaint alleged that the resident was transferred without his/her back brace applied, and without the required number of staff. Record review revealed the resident was admitted to the facility in November of 2023 with diagnoses including, but not limited to; fusion of spine lumbar region (surgery of lower spine), wedge compression fracture of the third lumbar vertebra (a fracture of the front of the lower part of the spine), and weakness. Record review of the hospital admission documentation revealed a REQUISTION FOR PROFESSIONAL SERVICES dated 11/16/2023 with treatment recommendations including, but not limited to, .brace 24/7 [all the time] x [for] 2 more weeks then D/C [discontinue] . Record review revealed a physician's order dated 11/22/2023 for skilled physical therapy evaluate and treat as indicated. Record review of the physical therapy (PT) evaluation and plan of treatment dated 11/22/2023 revealed .Precautions: *TLSO [Thoracic Lumbar Sacral Orthotic- back brace] for 1 more week as of 11/22/23 .Transfers .2 assist x FWW [Front Wheeled Walker] with TLSO [back brace]on when out of bed .transfers with gait belt . Record review revealed that on 11/23/2023, the resident sustained a fall while transferring with assistance of only one staff member, Staff A, from the bathroom in his/her room. Further review revealed Staff A did not utilize a gait belt and the resident was not wearing a back brace during the transfer and at the time of the fall. Record review revealed Staff A was hired by the facility on 9/26/2020 as a dietary staff member. Further review revealed Staff A graduated from the facility's Nursing Assistant (NA) training program on 10/23/2023. Additional review revealed Staff A had not been issued a temporary NA license by the Rhode Island Department of Health at the time of the fall. Record review of a progress note dated 11/23/2023 revealed 911 was called to assist with helping the resident off of the floor. Further review revealed the resident's family had requested that the resident be sent to the hospital for an evaluation however, the resident refused and was not transferred to the hospital. Record review of the November 2023 Medication Administration Record (MAR) revealed on 11/23/2023 the resident's pain level at bedtime was documented as a 7 (pain scale of 0-10, 10 being the worst pain). Further review revealed this pain level was after the fall which was a significant increase from the documented pain level of 0 at bedtime the night before. Additionally, record review revealed that the resident was administered Oxycodone 5 milligrams (mg) for pain on 11/23/2023 following the fall. Record review of an Occupational Therapy (OT) treatment encounter note dated 11/24/2023 revealed that not only does the resident require the assistance of two staff s/he now also requires a sit to stand aid for transfers. Further review revealed this was a .mobility status change .d/t [due to] pain level . and to ensure the resident's and staff safety. Record review of a PT treatment encounter note dated 11/25/2023 revealed that the resident had an increased fear of falling and a decreased step length. During a surveyor interview on 11/28/2023 at 12:50 PM with Staff A, he revealed that he was alone with the resident in the bathroom on 11/23/2023 and the resident insisted on transferring to bed, so he assisted him/her by himself and without a gait belt. He further revealed that the resident was not wearing a back brace at the time of the fall and that he was unaware that the resident required the use of the back brace. Additionally, he indicated that he was not a licensed NA. During a surveyor interview on 11/29/2023 at 9:21 AM with the Physical Therapist, Staff C she indicated that the resident has had an increased fear of falling and requires a stand aid for transfers since the fall on 11/23/2023. She further indicated that she would expect therapy recommendations to be followed by staff. Additionally, she indicated that she would have expected the resident to be transferred with two staff members and a gait belt. with the back brace in place. During a surveyor interview on 11/29/2023 at approximately 12:30 PM with Licensed Practical Nurse who is the Skilled Unit Manager, Staff D, she revealed that she entered the resident's physician's orders and reviewed the hospital documentation at the time of the resident's admission. She further acknowledged that she did not review the recommendation for the back brace, thus the order was not transcribed into the resident's record. Additionally, she revealed that the resident should have been a 2 person assist for transfers, with a gait belt, and with the back brace in place at the time of the fall on 11/23/2023. During a surveyor interview on 11/29/2023 at 9:37 AM with the resident's provider, Advanced Practice Registered Nurse Staff E, she indicated that she would have expected the resident to be transferred as recommended by PT. She further indicated that she would expect the resident to be wearing the back brace as recommended from the hospital following spinal surgery. During a surveyor interview on 11/29/2023 at approximately 2:00 PM with the Director of Nursing Services, he could not provide evidence that the PT recommendations for the assistance of two staff and the use of a gait belt with transfers, or the utilization of the back brace was followed. Additionally, he could not provide evidence that the facility ensured that the resident received adequate supervision and assistive devices to prevent an accident. As a result of the facility's failures to ensure that their staff are licensed, follow physical therapy recommendations made on 11/22/2023 for the resident to be assisted by two staff members, use a gait belt and to wear a back brace during all transfers, the resident who had recently undergone spinal surgery, was placed at risk for more than minimal harm, injury or death when s/he fell during a transfer on 11/23/2023.

Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to following up with the results of diagnostic testing, reporting a change in condition, and reporting recommendations from an outside provider to the attending physician for 1 of 5 residents reviewed for hospitalization , Resident ID #79. Findings are as follows: Review of a facility policy titled Resident Change in Condition last signed by the Director of Nursing Services (DNS) on 1/4/2023 states in part, .The facility will ensure that residents changes in conditions are identified timely, reported to the Physician and documented in the medical record timely .Changes in conditions require assessment by the RN [Registered Nurse] and notified to the MD [Medical Doctor] (both done timely) .Timely is certainly no later than the shift of the change . Record review revealed the resident was readmitted to the facility in May of 2022 with a diagnosis to include, but is not limited to, cerebral infarction (stroke). Record review revealed the resident had lab work obtained including a Hepatitis A, B, and C panel which was obtained on 8/4/2023. The lab work indicated a reactive Hepatitis A IgG (normal value is non-reactive). Record review revealed a progress note dated 8/7/2023 which revealed that a Hepatitis A, B, and C panel were obtained on 8/4/2023 and reported to the Physician, Staff A who in turn, provided a new order for a gastrointestinal consult to be obtained. Further record review failed to reveal evidence that the resident's condition related to his/her abnormal hepatitis panel was being monitored between 8/4/2023 through 10/11/2023. However, the record revealed the following indications that the resident was experiencing and displaying signs and symptoms of gastrointestinal issues: -The resident was seen by Staff A on 10/1/2023 and per Staff A's physician's note which stated, c/o [complained of] vague abdominal pain, mild, on and off . Additionally, it indicated that the resident's skin was dry with occasional bruises. -The resident was treated with antibiotics for a fever of unknown origin with an elevated white count from 10/8/2023 to 10/15/2023. Review of a document titled Referral Form dated 10/12/2023 revealed that the resident was being seen for an abnormal hepatitis panel. Further record review revealed the resident had elevated liver enzymes with a suspected drug induced liver injury. Further review revealed recommendations were made to avoid all hepatotoxic medications and to obtain a right upper quadrant abdominal ultrasound. According to Mosby's Drug Guide, dated 2014, indicates acetaminophen precautions are needed with patients with hepatic disease. The drug guide further revealed to assess for hepatotoxicity; dark urine, yellowing of skin and sclera, abdominal pain, fever, itching, diarrhea, if the patient is on long-term therapy. Record review revealed a physician's order with a start date of 7/25/2023 for acetaminophen (Tylenol) 1000 milligrams daily. Record review of the October 2023 Medication Administration Record revealed the resident received acetaminophen 1000 milligrams daily from 10/12/2023 through 10/25/2023, after the recommendation was made by the Gastroenterologist to avoid all hepatotoxic medications. Record review revealed an ultrasound was obtained on 10/18/2023 with the following results: .1. Mild hepatomegaly [enlarged liver] 2. Questionable wall echo shadow gallbladder sign [occurs when the Gallbladder wall contracts over Gallbladder stones]. Recommend CT [cat scan] to confirm . Record review failed to reveal evidence that the results of the ultrasound were reported to Staff A, including but not limited to, the recommendation to obtain a CT scan. Further review failed to reveal evidence that the facility obtained an order, scheduled, or that the patient received a CT scan as recommended by the Gastroenterologist on 10/18/2023. Record review of the October 2023 Medication Administration Record revealed the resident received Tums for complaints of an upset stomach on 10/15, 10/17, 10/21, twice on 10/22, 10/23, and 10/24/2023. During surveyor observations on the following dates and times revealed the resident's skin and sclera (whites of the eye) were yellow (jaundice-a condition with yellowing of the skin or whites of the eyes, arising from excess of the pigment bilirubin and typically caused by obstruction of the bile duct, by liver disease or by excessive breakdown of red blood cells) in color: - 10/24/2023 at 9:05 AM. - 10/25/2023 at approximately 9:05 AM. - 10/26/2023 at approximately 7:45 AM, while on a stretcher leaving the facility via Emergency Medical Services (EMS). Record review failed reveal evidence of documentation that the resident's skin and sclera were yellow in color or that Staff A was notified of the resident's change in skin and sclera color. Record review revealed a progress note dated 10/26/2023 at 8:15 AM, which revealed the resident was noted at 7:00 AM to be unresponsive. It further revealed that the resident was noted to move his/her eyes and mouth; however, no verbal response and no further motor responses were observed. S/he was then transported to the hospital via EMS. Record review of a document titled RI EMS Patient Care Report dated 10/26/2023 revealed that the resident was unconscious/unresponsive, jaundice with altered mental status. Review of the Hospital Emergency Department [ED] documentation dated 10/26/2023 revealed a CT scan was completed, which states in part, .Indications comment: Minimally responsive, jaundiced, ill appearing .FINDINGS .There is intra and extrahepatic biliary dilatation [gallbladder duct enlarged]. There is a 12 mm [millimeter] stone within the common bile duct .Gallbladder: Cholelithiasis [gallstones] with contracted gallbladder .IMPRESSION .Biliary dilatation secondary to a 12 mm common bile duct calculus. Gastroenterologist consultation recommend . Review of a progress noted dated 10/26/2023 at 5:55 PM revealed the resident was admitted to the hospital's medical intensive care unit with a diagnosis of choledocholithiasis (common bile duct stones, symptoms include, but are not limited to, fever, abdominal pain, upset stomach, nausea, vomiting, and jaundice). The resident experienced all these symptoms while residing in the facility as previously mentioned on 10/8/2023 through 10/26/2023, when s/he was transferred to an acute care hospital as s/he had become unresponsive and jaundice. During a surveyor interview with the Unit Manger RN, Staff B, on 10/27/2023 at 9:04 AM, she stated that the resident was jaundice and had been jaundice for about two weeks. Additionally, she was unable to provide evidence that Staff A was notified of the resident's significant change in condition as s/he was noted by staff to be jaundice in color. She was also unable to provide evidence of an assessment in the resident's record regarding the resident's change in skin color. She further revealed that the resident had a hepatitis panel obtained in August and Staff A ordered a gastrointestinal consult which was completed on 10/12/2023. Additionally, she revealed that the Gastroenterologist was concerned with the resident's liver functions and ordered an ultrasound. She was unable to provide evidence that the Staff A was aware of the ultrasound results with the recommendation for a CT scan related to concerns with the gallbladder. She revealed that she faxed the report to the Gastroenterologist and never heard back. She was unable to provide evidence that the facility attempted to contact the Gastroenterologist or that Staff A reviewed the results of the ultrasound including the recommendation for a CT scan. During a surveyor interview on 10/27/2023 at 8:39 AM with Staff A, he revealed he was unaware of the ultrasound results dated 10/18/2023 and would have ordered a CT scan to have been completed, as it was recommended. He also indicated that he was not aware of the recommendation to avoid all hepatotoxic medications and indicated that he would have discontinued the 1000 mg of acetaminophen that the resident had been receiving as a scheduled daily medication. Lastly, he revealed he was unaware that the resident had become jaundice in color and would have expected to have been notified. During a surveyor interview with the DNS on 10/27/2023 at 1:41 PM, he revealed that he noticed that the resident was jaundice a few days ago. Additionally, he was unable to provide evidence that he notified Staff A of the resident's change in skin and sclera color or that the ultrasound results were reported to the physician. Review of a Hospital document titled ED to Hosp- Admission .dated 10/27/2023, revealed the resident presented to the hospital with an acute change in mental status and jaundice for approximately 2 weeks and the resident had icteric (yellow) sclera and jaundice throughout. The document further revealed it was unlikely that the resident could pass the 12 mm stone spontaneously and would require interventions from the hospital. Further review of the document revealed the hospital plan is for an Endoscopic retrograde cholangiopancreatography (ERCP, a procedure that is performed when your bile or pancreatic ducts have become narrowed or blocked because of gallstones that form in your gallbladder and become stuck in your common bile duct) and was receiving Zosyn (an antibiotic) for a biliary obstruction and urinary tract infection. The document further revealed the resident's hemoglobin was documented as 4.3 g/dl (normal g/dl is 13.4 - 16.0) and the resident received 5 units of packed red blood cells. During a surveyor interview on 10/27/2023 at 3:38 PM and 10/30/2023 at 2:28 PM with the DNS, Assistant Director of Nursing Services, and the Administrator, they were unable to provide evidence that the facility followed up with results from diagnostic testing, reported a change in condition relative to a resident with a new onset of jaundice, and reporting recommendations from an outside provider to the attending physician. The facility's failures to follow up on the results of the ultrasound, report a change in condition relative to a new onset of jaundice, and report recommendations from the Gastroenterologist to the attending physician, which resulted in the resident being emergently transported to an acute care hospital, as s/he was found by the facility staff on the morning of 10/26/2023 unresponsive and jaundice in color resulting in the resident being admitted to the medical intensive care unit with diagnoses of severe anemia and choledocholithiasis.

Based on surveyor observation, record review, staff, and resident interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 4 residents reviewed, relative to a urinary tract infection (UTI), Resident ID #31. Findings are as follows: Record review of a facility policy titled, Urinary Incontinence and Indwelling Catheters states in part, .Symptomatic UTIs are based on the following criteria: Residents without a catheter should have at least three of the following signs and symptoms: .New or increased burning pain .New flank [the side of the body between the ribs and the hips] or suprapubic [lower abdomen] pain or tenderness .change in character of urine . Record review revealed Resident ID #31 was admitted to the facility in October of 2021 with diagnoses including, but not limited to, Parkinson's disease, repeated falls, and seizures. Record review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 11 out of 15, indicating the resident's cognition was moderately impaired. Further review revealed the resident was occasionally incontinent of urine. Record review revealed the following progress notes: - 10/12/2023 at 10:46 AM- complained of burning upon urination with amber colored urine and placed on the UTI protocol - 10/12/2023 at 2:35 PM- attempted to climb out of broda chair (a wheelchair that is padded and tilts) twice and complained of burning upon urination - 10/12/2023 at 9:26 PM- new pain or burning with urination and a change in character of urine (color, odor, clarity) was noted - 10/13/2023 at 6:59 AM- new flank/suprapubic pain or tenderness was noted Further record review failed to reveal evidence that the physician was notified of the resident's UTI symptoms, indicating that the facility policy was not followed, and a urinalysis was not obtained. During a surveyor interview on 10/25/2023 at 1:37 PM with Registered Nurse (RN) Staff D, he indicated that the resident was exhibiting symptoms of a UTI on 10/12/2023 and 10/13/2023 but was unable to provide evidence that the physician was notified in order to provide further recommendation or orders. During a surveyor interview on 10/25/2023 at 1:39 PM with the Registered Nurse Practitioner (RNP), she revealed that she was unaware the resident had been experiencing the above-mentioned symptoms and would have expected to be notified. Additionally, she indicated that she would have ordered a urinalysis (UA) to determine if the resident was positive for an UTI. During a surveyor interview on 10/25/2023 at 2:33 PM with the resident, s/he revealed that s/he was currently still experiencing burning with urination and that his/her urine was dark in color. Record review revealed a urine sample was obtained on 10/26/2023, after the surveyor brought the concern to the attention of the facility. The amber colored urine was sent to the lab for a UA with culture and sensitivity (to determine the type of bacteria causing the infection and the appropriate antibiotic treatment). Record review of the preliminary lab results dated 10/27/2023 revealed the resident was positive for a UTI. Record review revealed a physician's order dated 10/27/2023 for Cephalexin (antibiotic) 500 milligrams (mg) by mouth twice a day for 5 days. Further review revealed the medication was administered 10/27/2023 through 10/29/2023. Record review of a progress note dated 10/28/2023, revealed that the resident continued to complain of burning during urination. Record review of the final lab result dated 10/28/2023, revealed the resident was positive for a UTI including the specific organism responsible for the infection. Further review revealed the antibiotic medications that the organism was susceptible to. Record review of a progress note dated 10/29/2023 revealed the results were reported to the RNP and the antibiotic treatment was changed to Cipro (antibiotic) 500 mg by mouth twice a day for 5 days. During a surveyor interview on 10/25/2023 at 2:47 PM with the Director of Nursing Services (DNS), he was unable to provide evidence that the physician was notified of the resident's symptoms of a UTI, until it was brought to the facility's attention by the surveyor, despite the record indicating that the resident had documented UTI symptoms on 10/12/2023 and 10/13/2023. During an additional interview with the DNS on 10/30/2023 at 11:53 AM, he acknowledged that the resident had been diagnosed with a UTI and was receiving antibiotics to treat the infection. Additionally, he could not explain why the facility did not provide the appropriate treatment for the resident for 13 days following the onset of symptoms. This resident was experiencing symptoms of a UTI on 10/12/2023 and 10/13/2023 as documented in his/her medical record. The physician was not notified nor were any interventions or orders initiated. The surveyor brought this concern to the facility's attention on 10/25/2023 and urine was not obtained until 10/26/2023, which was positive for a UTI. This facility failure caused the resident a 13 day delay in treatment, prior to receiving treatment for a UTI.