Every finding on record at Warren Operations RI, LLC DBA Warren Center

Based on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 2 of 3 residents reviewed with an indwelling catheter (a flexible tube that collects urine from the bladder and leads to a drainage bag), Resident ID #s 9, and 62.Findings are as follows:According to Brunner & Suddarth's Textbook of Medical-Surgical Nursing Volume 2, 10th Edition, page 1282 states, For patients with indwelling catheters, the nurse assesses the drainage system to ensure that it provides adequate urinary drainage. The color, odor, and volume of urine are also monitored. An accurate record of fluid intake and urine output provides essential information about the adequacy of renal function and urinary drainage.Review of a facility policy titled CATHETER: INDWELLING URINARY-CARE OF states in part, .Monitor urine output color and notify physician.of abnormal changes .1. Record review revealed that Resident ID #9 was readmitted to the facility in June of 2025 with diagnoses including, but not limited to, obstructive uropathy (a blockage in the urinary system that hinders urine flow), urinary retention, acute kidney failure (an abrupt decrease in kidney function) and urinary tract infection.Review of a physician's order dated 8/29/2025 revealed the resident has an indwelling urinary catheter for obstructive uropathy.Record review of a care plan initiated 4/12/2025 revealed the resident requires an indwelling foley catheter relative to obstructive and reflux uropathy with interventions including, but not limited to, monitor output for odor, color, consistency, and amount.Further record review failed to reveal evidence of documentation that urinary output was monitored.2. Record review revealed that Resident ID #62 was readmitted to the facility in September of 2025 with diagnoses including, but not limited to, obstructive uropathy, urinary retention, tubule-interstitial nephritis (inflammation that affects the tubules of the kidneys and the tissues that surround them) and urinary tract infection.Record review revealed the resident has an indwelling urinary catheter for bilateral hydroureteronephrosis (a condition where the ureter and kidney swell due to urine flow obstruction).Record review of a care plan initiated 9/9/2025 reveals the resident requires an indwelling foley catheter relative to obstructive and reflux uropathy with interventions including, but not limited to, monitor output for odor, color, consistency, and amount.Further record review failed to reveal evidence of documentation that urinary output was monitored.During a surveyor interview on 9/19/2025 at 11:22 AM with the Director of Nursing Services, she was unable to provide evidence that the facility provided appropriate treatment and services for residents with a urinary catheter including documenting the urinary output. Additionally, she could not explain how the facility would identify an increase or a decrease in urinary output without the measurement of urine being documented.During a surveyor interview on 9/19/2025 at 1:17 PM with the Medical Director, he indicated it would be his expectation that the resident's output would be documented for resident with an indwelling urinary catheter.

Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of practice relative to physician's orders, for 1 of 1 resident who receives dialysis ( a medical procedure used to remove waste products and excessive fluid from the blood when the kidneys are no longer able to perform this function effectively), Resident ID #7. Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe that the orders are in error or would harm the clients.Record review revealed the resident was admitted to the facility in August of 2025 with diagnoses including, but not limited to, end stage renal disease and dependence on renal dialysis.Record review revealed the following physician's orders:-8/23/2025 cholecalciferol tablet (a dietary supplement) 1,000-unit one tablet daily-8/23/2025 citalopram hydrobromide (an antidepressant) 20 milligrams (mg) one tablet daily-8/23/2025 docusate sodium (a stool softener)100 mg one capsule daily-8/23/2025 ferrous sulfate (an iron supplement) 325 mg one tablet daily-8/23/2025 protein liquid one ounce daily-8/23/2025 quetiapine fumarate (a medication prescribed to treat schizophrenia, bipolar disorder, and major depressive disorder), 25 mg one tablet twice daily-8/22/2025 trazadone (a medication prescribed to treat depression) 50 mg 1/2 tablet from 7:00 AM to 12:00 PMRecord review of the August and September 2025 Medication Administration Records (MARs) failed to reveal evidence that the morning dose of cholecalciferol, citalopram hydrobromide, docusate sodium, ferrous sulfate, protein liquid, and quetiapine fumarate were administered as ordered on the following dates:-8/23/2025-8/26/2025-8/28/2025-9/4/2025-9/6/2025-9/11/2025-9/16/2025Additional review of the September 2025 MAR failed to reveal evidence that the trazadone was administered as ordered on the following dates and times:-9/4/2025, 7:00 AM to 12:00 PM dose-9/11/2025, 7:00 AM to 12:00 PM dose-9/16/2025, 7:00 AM to 12:00 PM doseDuring a surveyor interview on 9/19/2025 at 12:12 PM with the Director of Nursing Services she revealed that she would expect the medications to be administered as ordered. She was unable to provide evidence that the medications were administered on the above dates and times.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from any significant medication errors for 1 of 1 dialysis resident reviewed, Resident ID #7, and for 1 of 3 residents reviewed relative to blood pressure parameters, Resident ID #38.Findings are as follows: Review of a policy titled, Medication Administration revealed in part, .Prior to administration, review and confirm medication orders for each individual resident.Medications are administered in accordance with written orders of the prescriber.obtain and record any vital sign as necessary prior to medication administration.Medications to be given with meals are to be scheduled for administration at the resident's meal times.If two consecutive doses of a vital medication are withheld or refused, the physician is notified.1. Record review revealed Resident ID #7 was admitted to the facility in August of 2025 with diagnoses including, but not limited to, end stage renal disease and dependence on renal dialysis.Record review of the physician's orders revealed the following:-8/22/2025- Eliquis (a medication prescribed to reduce the risk of strokes and blood clots) 2.5 milligram (mg) one tablet every morning and at bedtime-9/3/2025- Renvela (a medication prescribed to control phosphorus levels in individuals with chronic kidney disease who are on dialysis) 0.8 grams give two packets three times daily at 8:00 AM, 12:00 PM, and 4:00 PM. This order was discontinued on 9/12/2025.- 9/12/2025- Renvela 0.8 gram give two packets three times daily at 8:00 AM, 12:00 PM and 5:00 PM.Record review of the Medication Administration Record (MAR) for September 2025 failed to reveal evidence that the resident received his/her Eliquis as ordered on the following dates and times:-9/4/2025- 7:00 AM- 10:00 AM dose-9/6/2025- 7:00 AM-10:00 AM dose-9/11/2025- 7:00 AM- 10:00 AM dose-9/16/2025- 7:00 AM - 10:00 AM doseRecord review of the Medication Administration Records (MARs) for August and September 2025 failed to reveal evidence that the resident received his/her morning dose of Renvela as ordered on the following dates:-8/26/2025-8/28/2025-8/30/2025-9/4/2025-9/6/2025-9/11/2025-9/13/2025-9/16/2025-9/18/2025During a surveyor interview on 9/19/2025 at 10:11 AM with Registered Nurse, Staff A, she acknowledged that the above medications were not administered as ordered.During a surveyor interview on 9/19/2025 at 10:56 AM with Nurse Practitioner, Staff H, she revealed that she would expect the resident to receive the medications as ordered.During a surveyor interview on 9/19/2025 at 12:12 PM with the Director of Nursing Services (DNS) she revealed that she would expect the medications to be administered as ordered. Additionally, she was unable to provide evidence that the medications were administered on the above dates and times.2. Record review revealed Resident ID #38 was admitted to the facility in May of 2025 with a diagnosis including, but not limited to, hypertension.Record review of the physician's orders revealed the following:-7/17/2025- Metoprolol Tartrate (a medication prescribed to treat high blood pressure) 25 mg one tablet every morning and at bedtime. The order includes the parameters to hold if the systolic blood pressure (is the pressure produced when the heart contracts and pushes out blood) is less than 100 or the pulse is less than 70.Record review of the MARs for August and September 2025 failed to reveal evidence that the resident's morning dose of Metoprolol Tartrate, was held due to parameters as ordered for the 7:00 AM-10:00 AM dose on the following dates:-8/12/2025-pulse of 66-8/16/2025-pulse of 66-8/19/2025-pulse of 67-8/22/2025-pulse of 66-8/29/2025-pulse of 65-8/31/2025-pulse of 67-9/2/2025-pulse of 65-9/5/2025-pulse of 60-9/9/2025-pulse of 63-9/12/2025-pulse of 62-9/16/2025-pulse of 68This indicates that for 11 out of 48 opportunities that the medication was administered outside of the ordered parameters between the dates of 8/1/2025 and 9/17/2025.Record review of the MARs for August and September 2025 failed to reveal evidence that the bedtime doses of Metoprolol Tartrate were held due to the parameters as ordered on the following dates:-8/4/2025-pulse of 69-8/6/2025-pulse of 66-8/8/2025-pulse of 66-8/9/2025-pulse of 69-8/11/2025-pulse of 69-8/15/2025-pulse of 65-8/16/2025-pulse of 67-8/18/2025-pulse of 61-8/20/2025-pulse of 64-8/21/2025-pulse of 60-8/22/2025-pulse of 60-8/23/2025-pulse of 67-8/24/2025-pulse of 65-8/27/2025-pulse of 69-8/28/2025-pulse of 62-8/29/2025-pulse of 62-8/30/2025-pulse of 68-9/6/2025-pulse of 69-9/8/2025-pulse of 60-9/9/2025-pulse of 53-9/10/2025-pulse of 64-9/14/2025-pulse of 66-9/15/2025-pulse of 62This indicates that for 23 out of 47 opportunities that the medication was administered outside of the ordered parameters between the dates of 8/1/2025 and 9/16/2025.During a surveyor interview on 9/18/2025 at 12:30 PM with Certified Medication Technician, Staff I, she acknowledged that the Metoprolol Tartrate was signed off as administered when the resident's pulse was less than 70.During a surveyor interview on 9/18/2025 at 12:35 PM with Licensed Practical Nurse, Staff J, she acknowledged that the Metoprolol Tartrate was given outside of parameters on the above dates.During a surveyor interview on 9/18/2025 at 12:40 PM with the DNS she acknowledged that the Metoprolol Tartrate should have been held due to a pulse below 70 on the above dates and times.

Based on record review and staff interview it has been determined that the facility failed to have sufficient staff who provide direct services to residents with the appropriate competencies and skill sets to provide nursing and related services, including training on caring for residents with mental and psychosocial disorders as well as residents with a history of trauma and/or post-traumatic stress disorder.Findings are as follows:Record review of the following staff members failed to reveal evidence of trauma informed care in-service training:- Nursing Assistant (NA), Staff D- hired on 5/16/2022- NA, Staff E- hired on 11/2/2024- NA, Staff F- hired on 4/18/2024- NA, Staff G- hired on 4/1/2025During a surveyor interview with the Director of Nursing Services on 9/19/2025 at 8:57 AM, she acknowledged that the trauma informed care in-service was not completed for the above staff members.

Based on record review and staff interview, it has been determined that the facility failed to implement comprehensive person-centered care plans for 4 of 6 residents reviewed for anticoagulation therapy (a medication that is prescribed to increase the amount of time it takes for blood to clot), Resident ID #s 4, 8, 62, and 64.Findings are as follows:1. Record review revealed Resident ID #4 was readmitted to the facility in May of 2025 with diagnoses including, but not limited to, atrial fibrillation (irregular heart rate) and history of transient ischemic attack (an episode of stroke-like symptoms caused by a brief blockage of blood flow to the brain).Record review revealed a physician's order dated 5/15/2025 for Eliquis 5 milligrams (mg) give one tablet every morning and at bedtime.Record review of a care plan initiated on 5/26/2025 includes a focus area of risk for injury or complications related to Eliquis (a medication prescribed to prevent strokes and blood clots) usage. Additionally, it revealed interventions to observe for signs of active bleeding including bruising, blood in the urine, blood in the stool, nose bleeds or bleeding gums.Record review failed to reveal evidence that the care plan for Resident ID #4 was being implemented relative to observing for signs and symptoms of abnormal bleeding.2. Record review revealed Resident ID #8 was readmitted to the facility in October of 2024 with a diagnosis including, but not limited to, chronic atrial fibrillation.Record review of a care plan initiated on 4/11/2024 includes a focus area of risk for injury or complications related to Eliquis usage. Additionally, it revealed interventions to observe for signs of active bleeding including bruising, blood in the urine, blood in the stool, nose bleeds or bleeding gums.Record review revealed a physician's order dated 10/28/2024 for Eliquis 5 mg give one tablet every morning and at bedtime.Record review failed to reveal evidence that the care plan for Resident ID #8 was being implemented relative to observing for signs and symptoms of abnormal bleeding.During a surveyor interview on 9/19/2025 at 10:30 AM with Registered Nurse (RN), Staff A, she was unable to provide any evidence that Resident ID #s 4 and 8 were being monitored for signs and symptoms of abnormal bleeding.3.Record review revealed Resident ID #62 was admitted to the facility in September of 2025 with diagnosis including, but not limited to, atrial fibrillation.Record review of a care plan initiated on 9/9/2025 included a focus area of risk for injury or complications related to the use of anticoagulation therapy. Additionally, it revealed a goal that resident will not exhibit signs and symptoms of bleeding X 90 days.Record Review revealed the following physician orders:-9/8/2025 for Warfarin Sodium (a medication prescribed to prevent blood clots) give 1.5 mg at bedtime. This order was discontinued on 9/12/2025-9/15/2025 for Warfarin sodium give 1 mg at bedtime. This order was discontinued on 9/16/2025-9/16/2025 for Warfarin sodium give 1 mg at bedtime.Record review failed to reveal evidence that the care plan was being implemented relative to observing for signs and symptoms of abnormal bleeding.4. Record review revealed Resident ID #64 was admitted to the facility in September of 2025 with diagnoses including, but not limited to, atrial fibrillation, embolism (a blockage in the blood vessel caused by a clot) and thrombosis (the formation of a clot) of the superficial veins of the lower extremity.Record review revealed a physician order dated 9/15/2025 for Warfarin Sodium 7.5 mg, give 1 tablet at bedtime.Record review of a care plan initiated on 9/16/2025 included a focus area of risk for injury or complications related to the use of anticoagulation therapy. Additionally, it revealed a goal that resident will not exhibit signs and symptoms of bleeding X 90 days.Record review failed to reveal evidence that the care plan was being implemented relative to observing for signs and symptoms of abnormal bleeding.During a surveyor interview on 9/19/2025 at 10:30 AM with Licensed Practical Nurse, Staff B, she was unable to provide evidence that Resident ID #s 62 and 64 were being monitored for signs and symptoms of abnormal bleeding.

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 monitoring of intake and output for 1 of 1 resident reviewed, Resident ID #59.Findings are as follows:According to Nursing, A Concept-Based Approach to Learning, Third Edition, Volume 1 dated 2019, page 366 and 370, acute kidney injury (AKI) is a rapid loss of renal function often accompanied by oliguria (voiding less than 500 milliliter [mL] per day) and electrolyte imbalance. A primary nursing intervention for AKI is closely monitoring the patient's fluid balance by tracking all intake and output over a 24-hour period, including oral fluids, ice chips, liquid foods, parenteral fluids, urine, emesis (vomit), liquid stool, and wound drainage.Record review revealed that the resident was admitted to the facility in June of 2025 with diagnoses including, but not limited to, cerebral infarction (stroke) and acute kidney injury with a creatinine level of 4.98 milligrams per deciliter (mg/dL) (a laboratory test that measures a person's kidney function with a normal range of 0.6 - 1.3 mg/dL. An elevated creatinine may be the result of kidney failure, dehydration, and other health condition).Record review revealed the resident was re-hospitalized on [DATE] with a continued diagnosis of AKI with a creatinine level of 5.93 mg/dL. S/he was sent back to the facility with the following recommendations including, but not limited to, have him/her drink at least 64 ounces (1892 milliliters) of liquids by 3:00 PM each day and if s/he has not consumed that amount of liquid by 3:00 PM, to administer 1 liter of normal saline. Additionally, if s/he stops making urine, stops eating or drinking, have him/her return to the emergency department for reevaluation.Record review of a physician progress notes written by Physician, Staff C, dated 6/17/2025 at 12:00 AM, revealed the resident was hospitalized on [DATE] due to an elevated creatinine of approximately 6 mg/dL and returned to the facility. The physician documented that the resident should be on strict intake and output to monitor his/her kidney function.Record review failed to reveal evidence that strict intake and output monitoring was implemented. During a surveyor interview on 9/19/2025 at 10:28 AM with the Physician, Staff C, she acknowledged that her expectation would be for the nurses to follow through with the strict intake and output monitoring as documented in her note.During a surveyor interview on 9/19/2025 at 10:55 AM with the Director of Nursing Services in the presence of the Administrator, she was unable to provide evidence that a strict intake and output monitoring was implemented for the resident.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide residents with the right to personal privacy and confidentiality of his/her personal and medical records relative to the posting of past survey results.Findings are as follows:During a surveyor observation of the main lobby area on 9/19/2025 at 7:30 AM, revealed a survey results binder.Record review of the survey results binder revealed copies of a previous recertification survey dated 8/16/2024 including the resident/staff roster which contained identifying information for 12 residents.During a surveyor interview on 9/19/2025 at 12:12 PM with the Administrator, she was unable to provide evidence that the facility protected the identifying information of the 12 residents listed in the survey results binder.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of a facility reported allegation submitted to the Rhode Island Department of Health on 12/17/2024 revealed that a family member of the resident alleged that the resident did not receive his/her inhaler resulting in a hospitalization . Record review revealed the resident was admitted to the facility in September of 2023 and readmitted in December of 2024 with diagnoses including, but not limited to, pneumonia and dysphagia (difficulty swallowing). Record review revealed a physician's order dated November 19, 2024, for Ipratropium-Albuterol solution 0.5-2.5 milligram/3 milliliter inhaler four times a day at 7:30 AM, 11:30 AM, 4:30 PM and 9:30 PM (before meals and at bedtime ), for wheezing and shortness of breath. Record review of the Medication Administration Record failed to reveal evidence that the resident received his/her inhaler on the following dates and times: - 11/19/2024 at 4:30 PM and 9:30 PM - 11/20/2024 at 7:30 AM, 11:30 AM, 4:30 PM, and 9:30 PM - 11/21/2024 at 7:30 AM, 11:30 AM, and 4:30 PM Additional record review failed to reveal evidence that the provider was notified that the resident had not received his/her inhaler on the above-mentioned dates and times, as ordered. During a surveyor interview on 12/18/2024 at 12:06 PM with the Director of Nursing Services (DNS), she acknowledged that the resident did not receive his/her inhaler on the above-mentioned dates and times as ordered. The DNS acknowledged that when the order was entered in the resident's record by the provider on 11/19/2024, the nurse on duty did not verify the order therefore is was not sent to the pharmacy for delivery, as per the facility's process. She further acknowledged that because of this failure, the inhaler was not delivered to the facility until 11/21/2024 at 9:18 PM, which led to the resident not receiving the inhaler on the above-mentioned dates and times. During a surveyor interview on 12/18/2024 at 12:32 PM with a Nurse Practitioner, Staff A, she revealed that she was unaware that the inhaler was not administered on the above-mentioned dates and times until after 11/21/2024. She indicated that she would have expected the nurse to have sent the order to the pharmacy on 11/19/2024 and would expect the staff to have administered the inhaler, as ordered.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 2 of 2 residents reviewed for insulin administration, Resident ID #s 15 and 204. Findings are as follows: 1. Record review revealed Resident ID #15 was readmitted to the facility in June of 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Record review revealed a physician's order dated 6/7/2024 for Lispro (insulin) inject 5 units with meals for diabetes. Hold if blood sugar (BS) is less than 150. Review of the July 2024 Medication Administration Record (MAR) revealed that his/her Lispro was given outside of parameters on the following dates and times: 7/6/2024 at 4:30 PM - BS 101 7/10/2024 at 4:30 PM - BS 120 7/12/2024 at 4:30 PM - BS 140 7/16/2024 at 7:30 AM - BS 120 7/18/2024 at 7:30 AM - BS 145 7/23/2024 at 4:30 PM - BS 128 7/26/2024 at 4:30 PM - BS 137 7/27/2024 at 4:30 PM - BS 119 Review of the August 2024 MAR revealed that his/her Lispro was given outside of parameters on the following dates and times: 8/2/2024 at 4:30 PM - BS 123 8/10/2024 at 4:30 PM - BS 140 8/11/2024 at 4:30 PM - BS 131 8/12/2024 at 11:30 AM - BS 121 8/12/2024 at 4:30 PM - BS 124 During a surveyor interview on 8/15/2024 at 1:30 PM with Registered Nurse, Staff K, she acknowledged that she administered the insulin outside of parameters on 8/12/2024. During a surveyor interview on 8/15/2024 at 1:34 PM with Registered Nurse, Staff L, she revealed that the facility's hold parameter is usually at 100 so she acknowledged that she administered the insulin outside of parameters on 7/6/2024 and 7/26/2024. 2. Record review revealed Resident ID #204 was admitted to the facility in August of 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Record review of a Nurse Practitioner's progress note dated 8/12/2024 at 8:42 PM revealed, .Orders .Okay to hold insulin glargine per conversation between resident and MD [physician] this morning and start [every AM] administrations tomorrow . Review of the August 2024 MAR failed to reveal evidence that the Glargine was administered to the patient on 8/13/2024, as ordered. Further record review of the MAR revealed an order for insulin Glargine 100 unit/ milliliter inject 20 units in the morning with a start date of 8/14/2024. During a surveyor interview on 8/15/2024 at approximately 9:20 AM with the Director of Nursing Services, she could not provide evidence that the Glargine was administered as ordered on 8/13/2024. 46118

Based on record review and staff interview, it has been determined that the facility failed to complete an annual performance review for every nurse aide (nursing assistant; NA), at least once every 12 months, for 3 of 3 NA personnel records reviewed, Staff H, I, and J. Findings are as follows: Record review of the personnel files failed to reveal evidence that an annual performance evaluation was completed for the following NAs: -Staff H, Date of hire-11/2007 -Staff I, Date of hire- 5/2023 -Staff J, Date of hire- 9/2015 During a surveyor interview with the Director of Nursing Services on 8/16/2024 at 9:45 AM, she was unable to provide evidence that performance evaluations were completed within the last 12 months for the above-mentioned employees prior to 8/15/2024 when it was brought to her attention by the surveyor.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to meet professional standards of quality for 1 of 1 resident reviewed with a physician's order for a Lidocaine patch, Resident ID #8; for 1 of 2 residents reviewed with orders for heel protectors, Resident ID #22; for 1 of 1 resident reviewed with a physician's order for TED stockings, Resident ID #26; and for 2 of 6 residents reviewed for weight loss, Resident ID #s 29 and 34. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. 1. Record review revealed Resident ID #8 was readmitted to the facility in June of 2024 with diagnoses including, but not limited to, mononeuropathy (damage or dysfunction of a single nerve usually affecting hands, arms, or feet) and arthropathy (disease of the joints). Record review revealed a physician's order dated 6/14/2024 for, Lidocaine external Patch 4% (used for pain) apply to left shoulder every morning and remove at bedtime. During a surveyor observation on 8/15/2024 at 8:52 AM during the medication administration task, Certified Medication Technician (CMT), Staff B, was observed removing a Lidocaine patch 4% from the resident's shoulder. This indicated that the patch failed to be removed at bedtime the night before. During a surveyor interview on 8/15/2024 at 9:24 AM, with Staff B, she acknowledged that the patch should have been removed at bedtime on 8/14/2024 per the physician's order. During a surveyor interview on 8/15/2024 at 11:29 AM with CMT, Staff C, she acknowledged that she failed to take the resident's Lidocaine patch off, as ordered, on 8/14/2024 at bedtime. 2. Record review revealed Resident ID #22 was admitted to the facility in May of 2024 with diagnoses including, but not limited to, muscle wasting, atrophy, type 2 diabetes mellitus and dementia. Record review revealed a physician's order dated 5/21/2024 to offload heels while in bed with pillows as tolerated every day and night shift for prevention and skin integrity. Additional review of an order dated 7/17/2024 revealed to wear heel protectors when in bed as tolerated every shift to maintain skin integrity. During surveyor observations on the following dates and times there was no evidence of the bilateral heel protectors, nor heels being offloaded while the resident was in bed. - 8/14/2024 at 8:18 AM - 8/16/2024 at 8:34 AM During a surveyor interview on 8/16/2024 at approximately 12:00 PM with the DNS, she acknowledged that the resident's heel protectors were not on and the heels were not offloaded, as ordered. 3. Record review of Resident ID #26 revealed s/he was readmitted to the facility in July of 2024 with diagnoses including, but not limited to, localized swelling, muscle weakness, and hypotension. Record review revealed a physician's order dated 8/5/2024 for TED stockings to be applied to bilateral lower extremities in the morning and to be removed at night for hypotension. During surveyor observations on the following dates and times there was no evidence of the bilateral TED Stockings observed while the resident was sitting in the wheelchair. - 8/13/2024 at 10:30 AM, 2:00 PM and 5:09 PM - 8/14/2024 at 10:00 AM During a surveyor interview on 8/14/2024 at 1:05 PM with Nursing Assistant, Staff D, in presence of the Registered Nurse, Staff E, they acknowledged that the resident was not wearing the TED Stockings as ordered. During a surveyor interview on 8/14/2024 at 1:48 PM with the DNS, she indicated that she expects staff to follow the physician's order. 4. Record review revealed Resident ID #29 was admitted to the facility in July of 2024 with diagnoses including, but not limited to, protein calorie malnutrition and age-related osteoporosis. Record review revealed a physician's order dated 7/25/2024 to obtain the residents weight weekly every Monday for 4 weeks. Record review of the recorded weights in the electronic medical record (EMR) and of the written weight log, failed to reveal evidence that the resident's weight was obtained on the week of 8/5/2024 as ordered. During a surveyor interview on 8/16/2024 at 10:16 AM with the DNS, she acknowledged that the resident's weight had not been obtained and documented for the week of 8/5/2024 as ordered. 5. Record review of Resident ID #34 revealed s/he was readmitted to the facility in July of 2024 with diagnoses including, but not limited to, altered mental status, respiratory failure and pneumonia. Record review revealed a physician's order dated 7/15/2024 to obtain the resident's weight every Monday for 4 weeks. Record review of the recorded weights in the EMR and of the written weight log, failed to reveal evidence that the resident's weight was obtained on the weeks of 7/29/2024 and 8/5/2024. During a surveyor interview on 8/16/2024 at approximately 10:00 AM with the DNS, she acknowledged that the resdient's weights had not been obtained and documented for the weeks of 7/29/2024 and 8/5/2024, as ordered. 46338

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that each resident receives adequate supervision by staff to prevent accidents relative to 1 to 1 supervision while eating for 1 of 4 residents reviewed, Resident ID #255. Findings are as follows: Record review revealed Resident ID #255 was admitted to the facility in August of 2024 with diagnoses including, but not limited to, traumatic subarachnoid hemorrhage (when blood bleeds into the space between the brain's surface), depression and cognitive communication deficit. Review of hospital documentation revealed the resident was observed after sustaining a traumatic brain injury. Additional review of the document dated 8/12/2024 revealed that s/he may need someone to help open container and lids, cut-up the food and may need help with eating. Record review revealed a physician order dated 8/13/2024 at 10:06 AM for regular/liberalized, dysphagia (difficulty swallowing) puree texture diet with a 1 to 1 supervision for all meals. During surveyor observation on 8/13/2024 from 12:18 PM to 12:51 PM, the resident was observed in bed with the lunch meal tray in front of him/her. Additional observation revealed that the plates were uncovered and set-up, but no staff was present for 1 to 1 supervision, as ordered. During a surveyor interview on 8/13/2024 at 12:25 PM with the resident, s/he indicated that s/he is afraid to feed him/herself because each time s/he does, s/he has a feeling of choking. During a surveyor observation on 8/14/2024 from approximately 8:30 AM to 8:53 AM, the resident was observed in bed with his/her meal tray set-up in front of him/her with no staff present for 1 to 1 supervision as ordered. During a surveyor interview on 8/14/2024 at 9:13 AM with NA, Staff B, she revealed that she does not know how the resident eats because s/he is not on her assignment. During a surveyor interview on 8/14/2024 at 9:28 AM with NA, Staff D, she revealed that she was unaware that the resident required 1 to 1 supervision for meals. During a surveyor interview on 8/14/2024 at 9:24 AM with the Unit Manager, Staff F, she stated the resident independently feeds him/herself. However, after checking the medical record she acknowledged that the resident needs 1 to 1 supervision with meals. During a surveyor interview on 8/14/2024 at approximately 10:30 AM with the Speech Therapist, Staff G, she revealed that the 1 to 1 supervision with all meals is for safety related to the diagnoses of dysphagia. During a surveyor interview on 8/15/2024 at approximately 11:00 AM, with the Director of Nursing Services, she was unable to provide evidence the resident's order for 1 to 1 supervision while eating was followed.

Based on record review and staff interview, it has been determined that the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 2 residents reviewed relative to falls resulting in injury, Resident ID #24. Findings are as follows: Record review revealed the resident was admitted to the facility in July of 2024 with diagnoses including, but not limited to, muscle weakness, cognitive communication deficit, and a history of falling. Review of the care plan dated 7/22/2024 revealed the resident was at risk for falls related to impaired mobility with interventions including, but not limited to, providing the resident with opportunities for choices, and to assist the resident in creating a clutter-free environment. Record review revealed the resident had fallen at the facility on the following dates: -8/1- twice -8/6 -8/8 Record review revealed the resident was sent to the hospital on 8/8/2024 following a fall. Further review revealed the resident was noted to have bruising around his/her eyes and forehead following the fall. Record review failed to reveal evidence that the comprehensive care plan had been updated with new interventions following each fall. The care plan was not updated until after the resident's fourth fall on 8/8/2024. During a surveyor interview on 8/16/2024 at 12:01 PM with the Director of Nursing Services, she could not provide evidence that the comprehensive care plan had been updated to include interventions to reduce falling risk on 8/1 and 8/6.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and practices for 5 of 13 residents reviewed related to documentation in the medical record, Resident ID #s 8, 22, 26, 29 and 34. Findings are as follows: 1) Record review revealed Resident ID #8 was readmitted to the facility in June of 2024 with diagnoses including, but not limited to, mononeuropathy (damage or dysfunction of a single nerve usually affecting hands, arms, or feet) and arthropathy (disease of the joints). Record review revealed a physician's order dated 6/14/2024 for Lidocaine external Patch 4% apply to left shoulder every morning and remove at bedtime. During a surveyor observation on 8/15/2024 at 8:52 AM during the medication administration task, Certified Medication Technician (CMT) Staff B, was observed removing a Lidocaine patch 4% from the resident's shoulder. This indicated that the patch failed to be removed at bedtime the night before. During a surveyor interview on 8/15/2024 at 9:24 AM, with Staff B, she acknowledged that the patch should have been removed at bedtime on 8/14/2024, per the physician's order. Record review of the Medication Administration Record revealed CMT, Staff C, had signed that the Lidocaine patch had been removed at bedtime on 8/14/2024. During a surveyor interview on 8/15/2024 at 11:29 AM with Staff C, she acknowledged that she failed to take the Lidocaine patch off the resident. She further acknowledged that she had initialed in the MAR that she had removed the patch. 2) Record review revealed Resident ID #22 was admitted to the facility in May of 2024 with diagnoses including, but not limited to, muscle wasting, atrophy, type 2 diabetes mellitus and dementia. Record review revealed a physician's order dated 5/21/2024 to offload heels with pillows while in bed, as tolerated, every day and night shift for prevention and skin integrity. Additional review of the order dated 7/17/2024 revealed heel protectors when in bed as tolerated every shift to maintain skin integrity. During surveyor observations on the following dates and times there was no evidence of the bilateral heels protectors, nor were heels offloaded while the resident was in bed. - 8/14/2024 at 8:26 AM - 8/16/2024 at 8:34 AM Record review of the Treatment Administration Record (TAR) revealed that the heel protector and the heels offloading with pillows tasks were signed off as completed on the above mentioned dates, but were not completed. During a surveyor interview on 8/16/2024 at approximately 12:00 PM with the DNS, she acknowledged that the resident's heels were not offloaded, and the heel protector were not on, as ordered. Additionally, she indicated that she would expect the nurse to only sign off an order if it had been completed. 3) Record review revealed Resident ID #26 was readmitted to the facility in July of 2024 with diagnoses including, but not limited to, localized swelling, muscle weakness, and hypotension. Record review revealed a physician's order dated 8/5/2024 for [NAME] stockings to be applied to bilateral lower extremities in the morning and to be removed at night for hypotension. During surveyor observations on the following dates and times there was no evidence of the bilateral [NAME] stockings observed while the resident was sitting in the wheelchair. - 8/13/2024 at 10:30 AM, 2:00 PM and 5:09 PM - 8/14/2024 at 10:00 AM, 12:00 PM During a surveyor interview on 8/14/2024 at approximately 11:30 AM with Resident ID #26 s/he revealed that s/he was never given [NAME] stockings. During a surveyor interview on 8/14/2024 at 1:05 PM with the NA, Staff D, in the presence of Registered Nurse, Staff E, they acknowledged that the resident was not wearing the [NAME] stockings. Record review of the Treatment Administration Record (TAR) revealed that Registered Nurse, Staff E, had signed off that the [NAME] stockings had been applied on 8/13/2024 and 8/14/2024, but these tasks were not completed. During a surveyor interview on 8/14/2024 at 1:48 PM with the DNS, she indicated that she would expect the nurse to only sign off on an order if it had been completed. 4) Record review revealed Resident ID #29 was admitted to the facility in July of 2024 with diagnoses including, but not limited to, protein calorie malnutrition and age-related osteoporosis. Record review revealed a physician's order dated 7/25/2024 to obtain the residents weight weekly every Monday for 4 weeks. Review of the August Medication Administration Record (MAR) revealed that a nurse documented that the resident's weight had been obtained on 8/5/2024; however, no weight was recorded. Record review of the recorded weights in the electronic medical record (EMR) and of the written weight log, failed to reveal evidence that the resident's weight was obtained on the week of 8/5/2024, as ordered. During a surveyor interview on 8/16/2024 at 10:16 AM, with the DNS, she acknowledged that the resident's weight had not been obtained and documented for the week of 8/5/2024 as ordered. Additionally, she indicated that she would expect the nurse to only sign off on an order if it had been completed. 5) Record review of Resident ID #34 revealed s/he was readmitted to the facility in July of 2024 with diagnoses including, but not limited to, altered mental status, respiratory failure, and pneumonia. Record review revealed a physician's order dated 7/15/2024 to obtain the resident's weight every Monday for 4 weeks. Review of the July and August MARS revealed that a nurse documented that the resident's weight had been obtained on 7/29/2024 and 8/5/2024. Record review of the recorded weights in the EMR and on the written weight log failed to reveal evidence that the resident's weight was obtained on the weeks of 7/29/2024 and 8/5/2024. During a surveyor interview on 8/16/2024 at approximately 10:00 AM, with the DNS, she indicated that she would expect the nurse to only sign off on an order if it had been completed. 46118 46338

Based on record review and staff interview, it has been determined the facility failed to provide written information to the resident or resident representative that specifies the facility's bed-hold bed payment policy before and upon transfer to a hospital from the facility for 5 of 6 residents transferred to the hospital, Resident ID #s 15, 21, 24, 51, and 205. Findings are as follows: Record review revealed the following residents were transferred to the hospital: - Resident ID #15 was transferred on 5/31/2024. - Resident ID #21 was transferred on 8/1/2024. - Resident ID #24 was transferred on 8/14/2024. - Resident ID #51 was transferred on 8/11/2024. - Resident ID #205 was transferred on 8/13/2024. Further record review failed to reveal evidence a bed hold policy was offered upon transfer to the hospital for the above-mentioned residents. During a surveyor interview on 8/16/2024 at approximately 1:30 PM, with business office, Staff A, she was unable to provide evidence the above-mentioned residents were given the opportunity to request a bed hold, as required. 41542 46118

Based on record review and staff interview, it has been determined that the facility failed to ensure that the assessment accurately reflected the resident's status for 1 of 1 resident reviewed for the use of mechanical lifts, Resident ID #1. Findings are as follows: Review of an anonymous community reported complaint submitted to the Rhode Island Department of Health on 2/9/2024 revealed the resident sustained a fall from a hoyer lift (mechanical lift) during a transfer resulting in a hematoma (swelling of clotted blood within the tissue) on his/her head. Record review revealed the resident was admitted to the facility in January of 2024 with diagnoses including, but not limited to, muscle weakness, disorders of the muscles, and repeated falls. Record review of a Lift Transfer Evaluation dated 1/9/2024 revealed the Recommendation/Care Plan for transfers was for a Total Lift [mechanical lift] Divided Leg Sling. Record review of a Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident required extensive assistance for transfers. Further record review failed to reveal evidence that the resident required a mechanical lift for transfers. Record review of the Nursing Assistant (NA) assignment sheet dated 1/27/2024 revealed the resident required a hoyer lift for transfers. Record review revealed the resident sustained a fall on 1/27/2024 while being transferred with one staff member into bed and without the use of a mechanical lift. During a surveyor interview on 2/12/2024 at approximately 12:00 PM with the Director of Rehab, she indicated that therapy had been working with the resident with transfers, however she would expect nursing to transfer the resident using the mechanical lift for safety. She further indicated that the resident's transfer status was communicated verbally to nursing following the completion of the Lift Transfer Evaluation on 1/9/2024. Additionally, she acknowledged a mechanical lift should be utilized by nursing for transfers for safety. During a surveyor interview on 2/12/2024 at 12:07 PM with the Director of Nursing Services, she was unable to provide evidence that the assessment accurately reflected the resident's status relative to the use of a mechanical lift. Cross Reference F689

Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to ensure that the residents' environment remains as free from accident hazards as possible for 1 of 2 residents reviewed with an actual fall, Resident ID #1. Findings are as follows: Review of an anonymous community reported complaint submitted to the Rhode Island Department of Health on 2/9/2024 revealed Resident ID #1 sustained a fall from a hoyer lift (mechanical lift) during a transfer resulting in a hematoma (swelling of clotted blood within the tissue) on his/her head. Record review revealed the resident was admitted to the facility in January of 2024 with diagnoses including, but not limited to, muscle weakness, disorders of the muscles, and repeated falls. Record review of a Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident required extensive assistance for transfers. Record review of the resident's care plan dated 1/10/2024 revealed the resident was at risk for falls related to impaired mobility. Record review of a Lift Transfer Evaluation dated 1/9/2024 revealed the Recommendation/Care Plan for transfers was for a Total Lift [mechanical lift] Divided Leg Sling. Record review of the Nursing Assistant (NA) assignment sheet dated 1/27/2024 revealed the resident required a hoyer lift for transfers. Record review revealed the resident sustained a fall on 1/27/2024 while being transferred with one staff member into bed and without the use of a mechanical lift. During a surveyor interview on 2/12/2024 at 11:34 AM with the resident's family member, she indicated that the resident had sustained multiple falls during his/her short admission to the facility, one resulting in injury. She further indicated that the resident was moved to another facility due to feeling as though the care was inconsistent and in fear that something detrimental could happen to the resident. During a surveyor interview on 2/12/2024 at 1:03 PM with the NA, Staff A, she revealed that on 1/27/2024 she assisted the resident from the bedside chair into the bed without the mechanical lift or the assistance of an additional staff member. She further revealed that the resident became weak, and they both fell to the floor. Additionally, she indicated that she frequently transferred the resident by herself and without the mechanical lift. During a surveyor interview on 2/12/2024 at approximately 12:00 PM with the Director of Rehab, she indicated that therapy had been working with the resident with transfers, however she would expect nursing to transfer the resident using the mechanical lift for safety. She further indicated that the resident's transfer status was communicated verbally to nursing following the completion of the Lift Transfer Evaluation on 1/9/2024, Additionally, she acknowledged a mechanical lift should be utilized by nursing for transfers for safety. During a surveyor interview on 2/12/2024 at 12:07 PM with the Director of Nursing Services, she acknowledged that the resident sustained a fall on 1/27/2024 while being transferred by one staff member and would have expected the resident to be transferred with the mechanical lift. Cross Reference F641

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: Record review revealed an undated document titled; Facility Assessment Tool which failed to reveal the following components, according to Appendix PP: - The overall acuity levels of the resident population - The staff competencies that are necessary to provide the level and types of care needed for the resident 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 - Staffing ratios for Licensed Nurses and direct care staff During a surveyor interview on 8/30/2023 at 11:20 AM with the Administrator, she acknowledged that the facility assessment was not complete. During a surveyor interview on 8/31/2023 at 9:55 AM with the Administrator, she revealed the facility assessment was last reviewed on 6/29/2022 and acknowledged that there were no signatures for the Medical Director, Infection Control Nurse, Food Service Manager, Human Resources, and Laundry Director. Additionally, she was unable to provide evidence that the template tool that the facility utilizes for their facility assessment was completed in its entirety. 45855

Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to ensure each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 27 opportunities for errors observed during the medication administration task, there were 3 errors resulting in an error rate of 11.1%. Findings are as follows: 1. Record review revealed Resident ID #43 has the following physician's orders - Lactulose (a medication used to treat constipation) Oral Solution 10 GM (gram)/15ML (milliliter) Give 30 ml by mouth every morning and at bedtime for Constipation. -MiraLax Oral Packet 17 GM (a medication used to treat constipation) Give 1 packet by mouth as needed for bowel management. Record review of the medication drug label for the Miralax revealed the bottle cap is a measuring cup designed to contain 17 grams of the powder when filled to the top rim. During a surveyor observation of the medication administration task on 8/30/2023 at 8:11 AM with Certified Medication Technician(CMT), Staff C, the resident's lactulose was not administered. Further observation, Staff C, was then observed to pour the Miralax into the cap of the medication bottle and fill approximately 3/4 of the cap. She then mixed the powder with the resident's beverage and administered the medication to the resident. During a surveyor interview immediately following the above observation with Staff C, she acknowledged she did not administer the Lactulose as ordered as it was unavailable. She further acknowledged she did not fill the Miralax to the top rim of the cap. 2. Record review revealed Resident ID #249 has a physician's order dated 8/25/2023 for Calcium-Vitamin D Tablet (600-200 Milligram-UNIT) Give 1 tablet by mouth one time a day for supplementation. During a surveyor observation of the medication administration task on 8/30/2023 at 8:15 AM with Staff C, the Calcium-Vitamin D was not administered. During a surveyor interview immediately following this observation with Staff C, she acknowledged she did not administer the Calcium-Vitamin D as ordered. During a surveyor interview with the Unit Manager, Staff D on 8/30/2023 at 3:00 PM, she acknowledged the above-mentioned errors. Additionally, she indicated she would expect that the staff reorder medication to be available and administered as ordered. She further acknowledged she would expect the resident to receive the correct dosage of medication.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who require a feeding tube receive the appropriate treatment and services to prevent complications for 1 of 1 resident reviewed who receives nutrition via feeding tube, Resident ID #22. Findings are as follows: Record review revealed the resident was readmitted to the facility in July of 2022 with a diagnosis including, but not limited to, gastrostomy complication (G-tube; an opening into the stomach from the abdominal wall, made surgically for the introduction of food). Record review revealed a physician's order for Jevity (nutrition delivered through a feeding tube) 1.5 calories (cal), 300 milliliters, three times a day and to hold if the resident consumes 50% or more for meals by mouth. Record review of the August 2023 Medication Administration Record revealed Jevity 1.5 cal was documented as being administered, when the resident had documentation of 50% or more of intake, on the following dates and mealtimes: - 8/21/2023 for lunch with a documented intake of 75% - 8/22/2023 for breakfast with a documented intake of 100% - 8/22/2023 for lunch with a documented intake of 100% - 8/22/2023 for dinner with a documented intake of 75% - 8/23/2023 for dinner with a documented intake of 50% - 8/24/2023 for breakfast with a documented intake of 75% - 8/26/2023 for dinner with a documented intake of 50% - 8/28/2023 for breakfast with a documented intake of 100% - 8/28/2023 for lunch with an intake of 100% - 8/28/2023 for dinner with a documented intake of 50% - 8/29/2023 for breakfast with a documented intake of 100% - 8/29/2023 for lunch with a documented intake of 100% - 8/30/2023 for dinner with a documented intake of 100% During a surveyor interview with Licensed Practical Nurse (LPN), Staff A in the presence of LPN, Staff B on 8/31/2023 at 9:45 AM, she revealed that she would expect the nurses to hold the resident's G-tube supplement when his/her intake is documented as 50% or more, per physician order.

Based on record review and staff interview, it has been determined that the facility failed to address the needs of every resident, including but not limited to, the resident at risk or already experiencing impaired nutrition for 1 of 5 sample residents reviewed for nutritional status (ID #32). Findings are as follows: The facility's policy titled Nutrition/Hydration Management reveals that the administration of oral supplements be documented. Record review revealed Resident ID #32 was admitted on [DATE] with diagnoses, which include, but are not limited to, dysphagia, age-related cognitive decline, restlessness and agitation, dementia with behavioral disturbance, heart failure, and pneumonia. Review of the resident's record revealed the following weights, indicating a 33.28% loss in one year; 15.59% in 6 months; and 7.33% in one month: -10/11/2017, 125 lb -4/17/2018, 98.8 lb -9/11/2018, 90 lb -10/9/2018, 83.4 lb Further record review revealed a care plan focus area that the resident is at nutritional risk: related to weight loss. Interventions include, juice supplement as ordered. Review of the record revealed the following: -5/1-5/31/2018 monthly orders signed by the practitioner for juice supplement 120 mL (milliliters) by mouth two times daily with corresponding Medication Administration Record [REDACTED] -Although the resident continued to lose weight, the 6/1-6/30/2018 monthly orders signed by the practitioner for juice supplement was decreased to 60 mL by mouth two times daily with corresponding MAR indicated [REDACTED] -Furthermore, 7/1-7/31/2018 monthly MAR, revealing juice supplement 60 mL by mouth two times daily with handwritten documentation stating, D/C indicating discontinue although there was no evidence of a physician's orders [REDACTED]. -8/8/2018 telephone order from the Registered Dietitian recommending: increase juice supplement to three times daily. There lacked evidence the supplement was administered -9/6/2018 telephone order signed by the practitioner to discontinue juice supplement During a surveyor interview with the Unit Manager on 10/22/2018 at 2:15 PM, she was unable to provide evidence that the nurses or medication technicians were administering the supplement. Additionally, she could not explain the discrepancies in the orders or why the order was discontinued on 9/6/2018. During a surveyor telephone interview with the physician on 10/23/2018 at 1:12 PM, he indicated that he was aware of the resident's weight loss. Additionally, he acknowledged that without documentation there is no evidence that the resident was given the supplement. During a surveyor telephone interview with the Dietitian on 10/24/2018 at 9:28 AM, she revealed that the intended amount of the juice supplements is 180 mL three times daily. Also, she was unaware of the order to discontinue the supplement and stated that the administration of the supplement should be documented in the resident's medical record.