Every finding on record at Westerly Health Center

Based on clinical record review and staff interview, the facility failed to notify the Office of the State Long-Term Care Ombudsman, when a resident is hospitalized or discharged and return to the facility is not anticipated, for 2 out of 3 residents reviewed for facility discharges, Resident ID #s 117 and 119.Findings are as follows:1. Record review revealed Resident ID #117 was admitted to the facility in September of 2023. Additional review revealed s/he was transferred to and subsequently admitted to the hospital on [DATE].Review of the facility's March 2026 Ombudsman Notification Log failed to reveal evidence that Resident ID #117 was listed on the log.2. Record review revealed Resident ID #119 was admitted to the facility in March of 2026. Additional review revealed s/he was discharged to the community on 3/30/2026.Review of the facility's March 2026 Ombudsman Notification Log failed to reveal evidence that resident ID #119 was listed on the log.During a surveyor interview on 5/29/2026 at 12:30 PM with the Social Worker. Staff A, she acknowledged that Resident ID #s 117 and 119 were not listed on the Facility's March 2026 Ombudsman Notification Log.During surveyor interviews on 6/1/2026 at 1:55 PM and at approximately 4:05 PM, with the Director of Nursing Services, she was unable to provide evidence that the Ombudsman had been notified of the above-mentioned residents discharged in March 2026.

Based on clinical record review, and resident and staff interview, the facility failed to provide necessary services to residents who are unable to carry out activities of daily living (ADLs) relative to scheduled showers, for 2 of 2 residents reviewed who alleged that they were not provided their scheduled showers, Resident ID #s 54 and 81.Findings are as follows: Review of a facility policy last updated on 2/19/2024, titled Bathing and Showering states in part, .Residents have the right to choose health care schedules consistent with their preferences including bathing/showering.Residents will be provided with a shower .as per their preference.1. Record review revealed Resident ID #81 was admitted to the facility in November of 2024 with diagnoses including, but not limited to, major depressive disorder and unsteady gait.Record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating the resident's cognition is intact. The MDS revealed that the resident requires extensive assistance for bathing/hygiene. Further review revealed that the resident's preference to receive a shower is very important.Review of a care plan dated 12/8/2024, revealed the resident has an ADL self-care performance deficit related to activity intolerance. Additional review of the care plan dated 1/29/2025 states s/he is to receive showers twice a week. Record review of a document titled 5 & 6 CNA (certified nursing assistant) list revealed, the resident is scheduled to receive showers twice weekly on Saturdays on the 7:00 AM to 3:00 PM shift and on Mondays on the 3:00 PM to 11:00 PM shift.Review of the documented shower's titled Task for Resident ID#81, revealed the resident was provided with a shower on 5/30/2026. Further review of the documentation revealed the resident had missed 7 scheduled showers in the last 30 days.During a surveyor interview on 5/27/2026 at 11:42 AM with Resident ID #81, s/he revealed that s/he has not been offered showers per his/her preference twice a week. 2. Record review revealed Resident ID #54 was admitted to the facility in March of 2026 with diagnoses including, but not limited to, major depressive disorder and difficulty walking.Record review of the admission MDS assessment dated [DATE], revealed a BIMS score of 9 out of 15, indicating the resident's cognition is moderately impaired. The MDS revealed that s/he requires extensive assistance for bathing/hygiene. Further review revealed that the resident's preference to receive a shower is very important.Review of a care plan dated 3/21/2026 revealed, the resident has an ADL self-care performance deficit related to impaired mobility.Record review of a document titled 5 & 6 CNA list revealed, the resident is scheduled to receive showers once a weekly on Sundays on the 7:00 AM to 3:00 PM shift.Record review of the documented shower's titled Task revealed that the resident did not receive any showers in the last 30 days. During a surveyor interview on 5/27/2026 at approximately 2:00 PM with Resident ID #54, s/he stated that it will be nice if staff would provide him/her their scheduled weekly shower.During a surveyor interview on 5/28/2026 at approximately 1:00 PM with Nursing Assistant, Staff B, she revealed that all the showers provided are documented under the resident's Task. However, review of the task documentation failed to reveal evidence that the resident had received any showers.During a surveyor interview on 6/1/2026 at 12:40 PM, with the Assistant Director of Nursing Services, she acknowledged that the Task documentation for Residents ID #54 and 81 failed to reveal evidence that both residents were offered their showers as scheduled per their preferred frequency.During a surveyor interview on 6/1/2026 at approximately 1:00 PM, with the Director of Nursing Services, she was unable to provide evidence that the residents were provided their showers as scheduled per their preference.

Based on clinical record review and staff interview, the facility failed to ensure a resident receives adequate supervision to prevent accidents for 3 of 5 residents reviewed who were identified as an elopement risk, Resident ID #s 15, 36, and 129. Findings are as follows:Record review of a facility policy titled Wander Management and Elopement Prevention last revised in November of 2025, states in part, .The facility will maintain the safety of residents who wander/or are at risk of elopement.5. When implementing a wander management system device, the staff will implement routine checks for placement and functionality.A. Wander management system device will be checked for placement each shift by nursing staff. B. Wander management system device will be checked daily for functionality by nursing staff.1. Record review revealed Resident ID #15 was originally admitted to the facility in April of 2026 with diagnoses including, but not limited to, Alzheimer's disease and dementia.Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the assessment due to impaired cognition. Further review revealed the resident ambulates with supervision and uses a wander/elopement alarm daily.Record review of a care plan initiated on 4/29/2026 revealed, the resident is at risk for elopement due to a wandering episode, with an intervention for a wander management device to be placed on the resident. Record review of an Elopement/Wandering Risk Evaluation dated 5/16/2026 revealed, the resident is at high risk for potential wandering/elopement.Surveyor observations of the resident on 5/27/2026 at 12:56 PM, and on 5/29/2026 at 12:23 PM revealed, the resident ambulating independently on the secured unit wearing a wander management device.Record review failed to reveal evidence of physician's orders for the implementation of a wander management device which includes; checking its placement each shift and functionality daily.During a surveyor interview on 6/1/2026 at 12:43 PM with the Director of Nursing Services (DNS), she acknowledged that the resident did not have physician's orders in place for the implementation of a wander management device. Additionally, she would expect the physician's orders to include checking the device's placement each shift and its functionality daily.2. Record review revealed Resident ID #36 was admitted to the facility in February of 2026 with diagnoses including, but not limited to, Alzheimer's disease and dementia.Record review of an admission MDS assessment dated [DATE], revealed a BIMS score of 12 out of 15 indicating moderate cognitive impairment. Further review revealed the resident ambulates with supervision and uses a wander/elopement alarm daily.Record review of a care plan initiated on 2/26/2026 revealed, the resident is at actual or potential risk for elopement, with an intervention for the use of a wander management device.Record review revealed the following physician's orders: -Check placement of the wander bracelet twice every 4 hours for safety, initiated on 3/3/2026.- Monitor for behaviors of exit seeking/packing belongings each shift, initiated on 3/7/2026.Record review of the May 2026 Medication Administration Record revealed exit seeking behaviors were documented on 5/5, 5/11, and 5/17/2026.Further review failed to reveal evidence of a physician's order to check the functionality of the wander management device.Surveyor observations of the resident on 5/27/2026 at 12:51 PM, 5/28/2026 at 9:26 AM, and 6/1/2026 at 10:29 AM, revealed s/he was ambulating independently on the secured unit wearing a wander management device.During a surveyor interview on 6/1/2026 at 12:43 PM with the DNS, she acknowledged that there was not a physician's order in place to check the functionality of the wander management device daily and would expect one to be in place.3. Record review revealed Resident ID #129 was admitted to the facility in May of 2026 with diagnoses including, but not limited to, dementia and adjustment disorder.Record review of an Elopement/Wandering Risk Evaluation dated 5/22/2026, revealed the resident is at risk for potential wandering/elopement.Record review revealed a physician's order dated 5/22/2026 to check placement of the wander management device every shift.Further review failed to reveal evidence the physician's order to check the functionality of the wander management device daily was implemented.Record review of the progress notes revealed, on 5/22/2026 the resident was walking independently without a rolling walker, presented with exit seeking behaviors, and a wander management device was placed on the resident. Further review of the progress notes revealed that on 5/25/2026, the resident was observed to pack his/her belongings in a bag and run down the hall after a family member as they were attempting to leave the secure unit. The resident stated, s/he wanted to go home.Surveyor observation on 5/27/2026 at 1:36 PM revealed the resident ambulating independently in his/her room on the secured unit wearing a wander management device.During a surveyor interview on 6/1/2026 at 12:43 PM with the DNS, she acknowledged that there was not a physician's order in place to check the functionality of the wander management device daily.

Based on clinical record review and staff interview, the facility failed to provide appropriate treatment and services for 2 of 3 residents reviewed with an indwelling urinary catheter (a flexible tube that collects urine from the bladder and empties into a drainage bag) related to urine output monitoring, for Resident ID #s 6 and 103.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.1. Record review revealed the Resident ID #6 was admitted to the facility in September of 2024 with a diagnosis including, but not limited to, urinary retention.Record review of a care plan initiated on 10/16/2025 revealed that the resident has an indwelling urinary catheter.Record review revealed the following physician's orders:- Provide urinary catheter care every shift with a start date of 2/24/2025- Change indwelling foley catheter on the 21st of each month with a start date of 11/11/2025 Further record review failed to reveal evidence of an order to monitor for color, odor, and urine output to adequately monitor renal function and urinary drainage.2. Record review revealed Resident ID# 103 was admitted to the facility in May of 2026 with a diagnosis including, but not limited to, type 2 diabetes mellitus.Record review of a care plan initiated on 5/13/2026 revealed that the resident has an indwelling urinary catheter.Record review revealed the following physician's orders:- Provide urinary catheter care every shift with a start date of 5/12/2026- Measure urinary output every shift and document the output in milliliters with a start date of 5/12/2026Record review of the Medication Administration Record for May 2026 revealed that the facility failed to document urine output for 10 of 59 opportunities, as ordered, to adequately monitor renal function and urinary drainage. Representing approximately a 17% failure rate to monitor. During a surveyor interview on 6/1/2026 at 1:28 PM, with the Director of Nursing Services, she acknowledged that Resident ID #6 did not have an order to monitor for urinary output and should have. Additionally, she acknowledged that the facility failed to accurately monitor urinary output for Resident ID #s 6 and 103.

Based on clinical record review and staff interview, the facility failed to store all drugs and biologicals in accordance with currently accepted professional principles for 1 of 1 resident found with medication in his/her room, Resident ID #27, 1 of 3 medication carts, and 2 of 2 medication storage rooms.Findings are as follows:Record review of a facility policy titled Medication labeling and storage revealed in part, .If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems.The medication label include, at a minimum.the expiration date, when applicable.resident's name.multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.Record review of a facility policy titled Administering Medications revealed in part, .The expiration/beyond use date on the medication label is checked prior to administering.1) Record review revealed Resident ID# 27 was admitted to the facility in March of 2022 with a diagnosis including, but not limited to, anxiety disorder.Record review revealed a physician's order dated [DATE] for diazepam (a medication prescribed to treat anxiety) 2 milligrams (mg) give 1/2 tablet (1 mg) twice daily.During a surveyor observation on [DATE] at 8:51 AM the resident revealed that s/he had three 1/2 tablets and one 1/4 tablet of diazepam in his/her room.During a surveyor interview and observation on [DATE] at 9:10 AM in the resident's room, in the presence of Registered Nurse (RN), Staff C, the resident provided the pills to the RN. Staff C acknowledged that the resident should not have the pills in his/her room.During a surveyor interview on [DATE] at 2:25 PM with the Director of Nursing Services (DNS), she acknowledged that the resident should not have the pills in his/her room.2) During a surveyor observation of the team two medication cart on the first floor in the presence of Medication Technician, Staff D, the following was revealed:-One Lidocaine 1% 200 mg/20 milliliter (ml) multi-dose bottle opened, and undated, with no resident name on the bottle.During a surveyor interview with Staff D at the time of the above observation, she acknowledged that the bottle failed to have a resident's name, and it was opened and undated.3a) During a surveyor observation of the second-floor medication room on [DATE] at 10:37 AM in the presence of Registered Nurse, Staff E, the following was revealed:- Two 2-ounce boxes of Good Sense hemorrhoidal ointment which expired on 8/2025.- Two bottles of Aspirin 325 mg which expired in 12/2025- One bottle of lorazepam 2mg/ml opened and undated. The manufacturer's instructions on the box state to discard the open bottle 90 days after opening.During a surveyor interview immediately following the observation, Staff E acknowledged that the above medications were expired and should have been discarded, and that the Lorazepam was opened and undated. She further revealed that she was unable to get into the other locked box which contained more lorazepam bottles.3b) During a surveyor observation of the second locked box in the second-floor medication room on [DATE] at 10:56 AM, in the presence of Licensed Practical Nurse (LPN), Staff F, the following was revealed:- Two bottles of lorazepam 2mg/ml opened and undated. The manufacturer's instructions on the boxes state to discard the open bottle 90 days after opening.- One bottle of lorazepam 2 mg/ml which was wet to the touch, opened and undated. This bottle failed to have a resident name that was able to be read, there was tape on the bottle, but it was illegible.During a surveyor interview at the time of the above observation, Staff F acknowledged that the three bottles of Lorazepam were opened and undated. She further acknowledged that the third bottle was wet with no legible resident name on the bottle.4) During a surveyor observation of the first-floor medication room on [DATE] at 11:14 AM, in the presence of LPN, Staff G, the following was revealed:- One bottle of Lorazepam 2mg/ml opened and undated. The manufacturer's instructions on the box state to discard the open bottle 90 days after opening.During a surveyor interview at the time of the above observation, Staff G acknowledged that the Lorazepam was opened and undated.During a surveyor interview on [DATE] at 1:10 PM with the DNS, she revealed that the lidocaine vial and the Lorazepam should have been labeled with a resident's name, and that all the above medications should have been dated when opened. She further revealed that the expired medication should have been discarded based on the expiration dates.

Based on clinical record review, and resident and staff interviews, the facility failed to provide reasonable accommodation of resident needs and preferences, for 1 of 1 resident reviewed related to providing an electric wheelchair to maintain comfort during independent mobility, Resident ID #44 who has bilateral lower extremity amputations. Findings are as follows:Record review revealed the resident was admitted to the facility in September of 2023 with diagnoses including, but not limited to, muscle weakness and absence of the right and left lower leg, below the knees.Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 15 out of 15, indicating the resident is cognitively intact. Further review revealed that the resident is independent with a slide board transfer (a mobility aid that helps individuals with limited mobility transfer from one surface to another), and the use of a manual wheelchair.Record review of a care plan initiated on 11/10/202,3 for potential for pain, revealed an intervention to refer to Physical Therapy and/or Occupational Therapy, as needed.Record review of an Occupational Therapy (OT) Evaluation and Plan of Treatment dated 3/31/2026, revealed that the resident was evaluated and complained of bilateral shoulder pain. Additionally, the resident feels that a power wheelchair may help with his/her shoulder pain. Further review of the OT evaluation failed to reveal evidence recommendations for a power wheelchair were made or that the bilateral shoulder pain was addressed.During a surveyor interview on 5/27/2026 at 9:12 AM with the resident, s/he revealed that s/he transfers via a slide board independently and self-propels in his/her manual wheelchair. Additionally, s/he experiences pain in his/her bilateral shoulders due to lifting his/her body and pushing the wheels of the wheelchair throughout the day. The resident indicated s/he had spoken to the facility staff about obtaining a power wheelchair but has not heard back.Record review of a Radiology Results Report dated 4/21/2026, revealed that x-rays were obtained with results indicating Osteoarthritis (a form of arthritis that occurs with the protective cartilage that cushions the ends of the bones wears down overtime, leading to pain, stiffness, and reduced mobility) of the right and left shoulder and shoulder joints.Record review of a progress note dated 4/21/2026, authored by the Nurse Practitioner (NP), Staff H, revealed the resident was seen by the NP secondary to bilateral shoulder pain and discomfort with known osteoarthritis. The resident consulted with the facility's orthopedic provider and the provider recommended bilateral shoulder x-rays to compare with previous x-rays, from roughly 2 years ago. Additionally, the progress note revealed the findings of arthritis of the bilateral shoulders and shoulder joints. Further review indicated the resident continued to endorse pain and discomfort. S/he is wheelchair-bound and constantly utilizing both arms to get around; this is suspected to be increasing his/her pain and arthritis from overuse. Furthermore, the progress note revealed the provider will collaborate with the orthopedic provider regarding the findings of the x-rays.Record review of a progress note dated 4/30/2026, authored by the Orthopedic Provider, Staff I, revealed the resident complains of chronic pain to his/her shoulders which s/he thinks may be because of using his/her wheelchair to mobilize. She/he notes constant aching in the shoulders which seems to be worsened by overuse. Additional review revealed she/he is requesting use of a power wheelchair and this would be a reasonable accommodation.Record review of a facility provided document titled Orthopedic Program Rounds dated 5/14/2026, revealed a recommendation from the provider for use of a powered wheelchair, three days per week.During surveyor interview with the Director of Nursing Services on 5/31/2026 at 1:55 PM, she acknowledged that she was aware that the resident was requesting an accommodation of a motorized wheelchair secondary to bilateral upper extremity pain. Additionally, she was unable to provide evidence that the facility followed up and/or provided such accommodation.

Based on clinical record review and staff interview, the facility failed to ensure that the assessment accurately reflected the resident's status for 1 of 2 residents reviewed related to smoking, Resident ID #62, and 1 of 3 residents reviewed related to a misspelled name, Resident ID #38.Findings are as follows:1) Record review revealed Resident ID# 62 was admitted to the facility in July of 2023, with diagnoses including, but not limited to, major depressive disorder and anxiety disorder. Record review of a physician's order dated 3/13/2025, revealed the resident may smoke with staff up to 4 times per day. It further revealed all smoking materials were to be locked in the nursing cart, and a smoking apron must be worn.Review of a smoking safety evaluation dated 6/4/2025, revealed the resident currently smokes cigarettes, 2-3 times daily.Review of an Annual Minimum Data Set (MDS) assessment dated [DATE], revealed O was coded for Section J1300, indicating that the resident does not currently use tobacco products.2) Record review revealed Resident ID #38 was admitted to the facility in December of 2025, with diagnoses including, but not limited to, congestive heart failure and dementia.Review of Resident ID #38's Entry MDS dated [DATE], revealed the resident's name was misspelled in Section A6500, Last Name. Review of an admission MDS, dated [DATE], found this resident's name spelled correctly, though the Entry MDS was not revised with the correct name.During a surveyor interview on 5/29/2026 12:03 PM, with the Regional MDS Coordinator, she acknowledged that the MDS assessments mentioned above were inaccurately coded. She further acknowledged Resident ID #62 should have been coded that the resident does currently use tobacco products, and Resident ID #38's name should have been corrected on the Entry MDS.During a surveyor interview on 5/29/2026 at 1:17 PM, with the Director of Nursing Services, she indicated that she would expect the MDS assessments to accurately reflect the resident's status.

Based on clinical record review and staff interview, the facility failed to develop and implement a baseline care plan, for 1 of 1 newly admitted resident identified as an elopement risk, Resident ID #129.Findings are as follows:Record review revealed the resident was admitted to the facility in May of 2026 with diagnoses including, but not limited to, dementia and adjustment disorder.Record review of an Elopement/Wandering Risk Evaluation dated 5/22/2026, revealed the resident is at risk for potential wandering/elopement.Record review of progress notes revealed that on 5/22/2026, the resident was walking independently without a rolling walker, presented with exit seeking behaviors and a wander management device was placed on the resident. Further review of progress notes revealed that on 5/25/2026, the resident was observed to pack his/her belongings in a bag and run down the hall after a family member as they were attempting to leave the secure unit, the resident stated s/he wanted to go home.Record review failed to reveal evidence of a completed baseline care plan, initiated within 48 hours after admission, which included interventions for an identified elopement risk. During a surveyor interview on 6/1/2026 at 12:42 PM with the Director of Nursing Services, she revealed it was her expectation the resident's identified elopement risk would have been included in his/her baseline care plan.

Based on clinical record review and staff interview, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team, for 1 of 2 residents reviewed, Resident ID #44.Findings are as follows:Record review revealed Resident ID# 44 was admitted to the facility in August of 2023, with a diagnosis including, but not limited to, Chronic Obstructive Pulmonary Disease.Record review revealed a Physician's order dated 4/9/2026, indicating that the resident may smoke up to four times per day and all smoking implements must be stored in the medication cart.Review of the resident's comprehensive care plan dated 10/7/2025, revealed an intervention including, but not limited to, the resident may store all smoking materials in his/her room. Further review failed to reveal evidence the care plan was revised after the order was given for nursing to store all smoking implements in the medication cart.During a surveyor interview on 5/29/2026 at 1:18 PM with the Director of Nursing Services, she acknowledged that the care plan failed to be revised and should have been.

Based on surveyor observation, clinical record review, staff and resident representative interviews, it has been determined that the facility failed to ensure that a resident receives proper treatment to maintain hearing abilities for 1 of 1 resident reviewed for hearing concerns, Resident ID #46. Findings are as follows:Record review revealed the resident was admitted to the facility in May of 2023 with diagnoses including, but not limited to, mild cognitive impairment and major depressive disorder.Record review of a care plan dated 8/7/2024 states the resident is hard of hearing related to the aging process with an intervention to provide him/her with appropriate hearing aids as required and a goal to be able to communicate effectively with staff with dignity.Record review of the Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 7 out of 15, indicating the resident's cognition is severely impaired. Further review of the MDS revealed that his/her ability to hear is highly impaired.1a) During a surveyor interview on 5/27/2026 at 11:12 AM with the resident, s/he was unable to hear, s/he stated, I can't hear anything that you are saying.Review of a physician's order dated 3/20/2026 revealed Debrox (a medication to soften the earwax before its removal) Solution 6.5% to instill 5 drops in both ears twice a day for 4 days related to earwax. Record review of March of 2026 Medication Administration record failed to revealed evidence that the resident received the Debrox Solution on the following days and times: 3/20/2026 - 8:00 PM 3/21/2026 - 8:00 AM 3/21/2026 - 8:00 PM This indicates that s/he missed 3 doses out of 8 opportunities. 1b) During a surveyor observation on 5/28/2026 at 12:19 PM, the resident was observed in his/her room with no evidence of a hearing aid.Record review failed to reveal evidence of the resident receiving any hearing device per his/her plan of care.During a surveyor interview following the observation with Nursing Assistant, Staff K, she revealed that the resident is hard of hearing however, s/he has an amplifier that was brought by a family member to help communicate with the resident. Additionally, Staff K was observed taking the amplifier out of the resident's drawer then applying it to the resident's ears. Further the resident was observed smiling saying thank you, now I can hear. Further, Staff K was unable to explain why the amplifier was not applied to the resident prior to being brought to her attention by the surveyor.During a surveyor interview on 5/28/2026 at 12:31 PM with Registered Nurse Staff L, she acknowledged that the resident is hard of hearing. Additionally, she stated that she was unaware that the resident had an amplifier. When Staff L was asked why the amplifier was not being applied to the resident, she acknowledged that there is no order to apply it.During a surveyor interview on 5/28/2026 at approximately 1:00 PM, with the Director of Nursing Services, she was unable to provide evidence that the resident received the Debrox solution as ordered. Additionally, she revealed that she was not aware of the amplifier usage by the resident as she was unable to provide evidence of a physician's order.During a surveyor interview on 5/28/2026 at approximately 2:00 PM with the provider, he revealed that he would have expected the resident to receive the Debrox Solution as ordered. Additionally, he indicated that he was not made aware of the amplifier application to the resident. Further, he indicated that he would expect the staff to notify him to obtain an order for the hearing device per the resident's plan of care.

Based on surveyor observation, clinical record review, resident, and staff interview, the facility failed to ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM for 1 of 1 resident reviewed, Resident ID #10. Findings are as follows:Record review revealed Resident ID #10 was readmitted to the facility in June of 2025 with diagnoses including, but not limited to, right femur fracture, difficulty walking and chronic pain.Record review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Further review revealed the resident had impaired range of motion of both sides of his/her lower extremities.Review of the comprehensive care plan dated 1/7/2026, revealed the resident had a right hip fracture related to a fall, with identified care plan interventions that included, but were not limited to, monitoring, documenting, and reporting signs and symptoms of fracture-related complications to the physician, including contracture formation; ongoing assessment and evaluation of the resident's need for adaptive devices; and consultation with Physical Therapy to address functional limitations and promote mobility.During a surveyor observation and simultaneous interview on 5/27/2026 at 11:53 AM, the resident was observed sitting in his/her wheelchair. His/her bilateral feet were observed to be maintained in a pronounced plantar-flexed position (a position where the feet and toes are pointing downward). The resident revealed that s/he has been discharged from therapy and wanted to continue service to improve his/her mobility.Record review revealed the resident received Physical Therapy Services from 3/24/2026 through 5/19/2026.Record review of a Physical Therapy Encounter Treatment Note dated 5/16/2026, revealed a planned discharge date of 5/19/2026. The treatment note documented a recommendation to obtain a plantar flexion contracture splint (a device designed to maintain proper positioning and alignment of an extremity to preserve or improve joint mobility) to address the resident's plantar flexion of his/her bilateral feet and promote dorsiflexion of the foot (movement of the foot upward toward the shin).Record review of the PT Discharge Summary dated 5/19/2026, revealed discharge recommendations to acquire the plantar flexion (PF) contracture boots.During an interview conducted on 6/1/2026 at 11:01 AM, with the Director of Rehabilitation, she acknowledged that the resident was discharged from Physical Therapy services on 5/19/2026 with a recommendation for PF contracture boots. She revealed that the recommended boots required a vendor appointment for assessment and custom fitting. She further acknowledged that it was her responsibility to follow up and arrange the appointment to obtain the recommended device. However, she acknowledged that, as of 6/1/2026, no appointment had been scheduled and no follow-up action had occurred, approximately 15 days after the recommendation was made.During an interview conducted on 6/1/2026 at 1:55 PM, the Director of Nursing Services acknowledged she was not aware that the resident had a Physical Therapy discharge recommendation for PF contracture boots related to limited range of motion of the lower extremities. She stated she would have expected that such a recommendation would have been communicated to nursing staff at the time it was made to ensure appropriate follow-up and coordination of care.During a surveyor interview on 6/1/2026 at 2:10 PM with the Medical Director, he indicated that typically there would be communication from therapy to nursing to obtain an order for the PF contracture boots. Additionally, he indicated he would expect the facility to follow up within approximately a two-week time frame to obtain an appointment for the fitting of the contracture boots.

Based on clinical record review and staff interview, the facility failed to ensure that residents are free from significant medication errors for 1 of 1 resident reviewed for the administration of an intramuscular antibiotic (a medical procedure where the medicine is delivered directly into the muscle tissue), Resident ID #64.Findings are as follows:Record review of the facility policy titled, Administering Medications states in part, .Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber orders, including the required time frame.Record review revealed the resident was admitted to the facility in September of 2025 with a diagnosis, including but not limited to, chronic kidney disease.Record review of a lab report revealed a urine specimen was obtained on 5/21/2026. This lab report indicated that on 5/25/2026 a report was sent to the facility that the resident tested positive for a urinary tract infection, and that the organism could be treated with Ertapenem (an antibiotic prescribed to treat urinary tract infections).Record review revealed a physician's order dated 5/25/2026 for Ertapenem sodium injection solution 1 Gram (GM) intramuscularly, for urinary tract infection, for 5 days. This order had a start date of 5/25/2026 and continued through 5/29/2026, indicating that 5 doses should have been given to the resident.Record review of the facility provided Packing slip Proof of Delivery from the pharmacy, revealed that 5 doses of Ertapenem were delivered for the resident, 3 doses on 5/25/2026 and 2 doses on 5/27/2026.Record review of the May Medication Administration Record revealed that the Ertapenem was not signed off as administered on 5/27/2026.During a surveyor observation of the medication cart on 6/1/2026 at 10:38 AM, with Registered Nurse, Staff L revealed two doses of Ertapenem in the medication cart with the resident's name on them.During the above observation Staff L acknowledged that the Ertapenem was not signed off as administered on 5/27/2026. She further acknowledged the unopened dosages left in the medication cart for the resident.During a surveyor interview on 6/1/2026 at approximately 1:30 PM with the Director of Nursing Services, she was unable to provide evidence that any Ertapenem, beyond the 5 doses listed above, had been obtained for the resident. Additionally, she was unable to explain how the resident received the 5 doses that were ordered by the physician if there were 2 doses remaining in the medication cart.

Based on 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 4 residents reviewed for antibiotic use, Resident ID #s 10 and 64. Findings are as follows:According to the Centers for Disease Control and Prevention (CDC) document titled, The Core Elements of Antibiotic Stewardship for Nursing Homes states in part, Perform antibiotic 'time outs.' .Nursing homes should have a process in place for a review of antibiotics by the clinical team two to three days after antibiotics are initiated to answer these key questions: Does this resident have a bacterial infection that will respond to antibiotics? If so, is the resident on the most appropriate antibiotic(s), dose, and route of administration? Can the spectrum of the antibiotic be narrowed or the duration of therapy shortened (i.e., de-escalation)? Would the resident benefit from additional infectious disease/antibiotic expertise to ensure optimal treatment of the suspected or confirmed infection . 1. Record review revealed that Resident ID #10 was readmitted to the facility in March of 2026 with a diagnosis including, but not limited to, elevated white blood cell count.Record review revealed a physician's order dated 5/21/2026 for Amoxicillin Pot Clavulanate (an antibiotic) tablet 875-125 milligrams (mg) every 12 hours for 7 days, from 5/21/2026 through 5/28/2026.Record review revealed an antibiotic time out form was initiated on 5/23/2026 but was not completed.2. Record review revealed that Resident ID #64 was admitted to the facility in September of 2025 with a diagnosis including, but not limited to, chronic kidney disease.Record review revealed a physician's order dated 5/25/2026 for Ertapenem Sodium (an antibiotic) injection 1 Gram daily for 5 days, from 5/25/2026 through 5/29/2026.Record review failed to reveal evidence that an antibiotic time out was completed.During a surveyor interview on 6/1/2026 at approximately 1:15 PM with the Director of Nursing Services, she was unable to provide evidence that antibiotic time outs were completed for the above two residents who were receiving antibiotics.

46118 Based on record review and staff interview, it has been determined that the facility failed to ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight for 1 of 3 residents reviewed with a severe weight loss, Resident ID #99. Findings are as follows: Review of the facility policy titled Weight Assessment and Intervention revised in March of 2022, states in part, .1. Residents are weighed upon admission and at intervals established by the interdisciplinary team. 2. Weights are recorded in each unit's record chart and in the individual's medical record. 3. Any weight change of 5 % or more since the last weight assessments is retaken the next day for confirmation. a. If the weight is verified, nursing will immediately notify the dietician in writing . 5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria . a. 1 month-5% weight loss is significant: greater than 5% is severe. b. 3 months-7.5% weight loss is significant: greater than 7.5% is severe . Care Planning 1. Care planning for weight loss or impaired nutrition is a multidisciplinary effort . Record review revealed Resident ID #99 was admitted to the facility in January of 2025 with a diagnosis including, but not limited to, muscle wasting. Record review revealed a care plan initiated on 1/13/2025 for a weight loss trend and a calorie expenditure from walking around the unit throughout the day. Further review revealed a goal for no significant weight loss or trending weight loss. Additional review revealed interventions to obtain weights as ordered and for the Registered Dietitian (RD) to evaluate the resident's nutritional status and to make recommendations as applicable. Record review revealed a physcian's order dated 1/10/2025, weight on admission, then weekly weight x 4, then monthly. Record review revealed the following weights: -1/10/2025- 153.9 pounds (lbs.) -1/13/2025- 154.2 lbs. -2/3/2025- 148.5 lbs. -3/6/2025- 144.8 lbs. The above weights indicated a weight loss of 5.91% (9.1 lbs.) in approximately 2 months, from 1/10 to 3/6/2025. Review of a progress note, dated 4/17/2025 authored by the RD, revealed the most recent weight was obtained on 3/6/2025 and a weight had not yet been obtained for the month of April. Further review revealed the dietitian requested that a weight be obtained to assess if the resident's needs are being met. Record review failed to reveal evidence that a weight had been obtained after the above recommendation. Further review failed to reveal evidence that any interventions were implemented for the resident's weight loss. During a surveyor interview on 4/23/2025 at 8:43 AM and at 9:59 AM with Registered Nurse (RN), Staff C, she indicated that the residents are weighed at least monthly, usually by the 5th of each month. Staff C acknowledged that the resident's weight had not been obtained since 3/6/2025 and indicated that she was unaware of the RD's recommendation to obtain the resident's weight on 4/17/2025. During a surveyor interview on 4/23/2025 at 8:46 AM with the RD, she indicated that she would expect weights to be obtained upon a resident's admission, then weekly for four weeks, and then monthly for each resident. Additionally, she indicated that she would have expected the resident's weight to have been obtained as she requested. During a surveyor interview on 4/23/2025 at 9:50 AM with the Director of Nursing Services and the Regional Director of Clinical Services, they indicated that they would expect weights to be obtained monthly or as ordered. Additionally, they acknowledged that the resident's weight had not been obtained since 3/6/2025. During a subsequent surveyor interview on 4/23/2025 at 2:15 PM with RN, Staff C, she revealed that the resident's weight was obtained after it was brought to her attention by the surveyor. Staff C indicated the resident's weight is now 137.2 lbs., indicating s/he has a further weight loss of 7.6 lbs. This indicates a severe weight loss of 10.85% (16.7 lbs.) from 1/10 to 4/23/2025. Further review failed to reveal evidence that any interventions were implemented for the resident's severe weight loss from 1/10/2025 until 4/23/2025 when it was brought to the facility's attention by the surveyor.

Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality related to following physician's orders for 1 of 1 resident reviewed with an order for Mucinex (a medication prescribed to thin mucus), Resident ID #52 and for 1 of 1 resident reviewed with an order for Metoprolol Succinate Extended Release (a medication prescribed to treat high blood pressure), Resident ID #63. 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 the orders are in error or would harm the clients . 1. Record review revealed Resident ID #52 was originally admitted to the facility in April of 2024 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD; a condition involving constriction of the airways) and chronic pulmonary edema (a condition in which the lungs accumulate too much fluid). Record review revealed a physician's order dated 4/20/2025 for Mucinex 600 milligrams (mg) twice a day for three days. Record review of the April 2025 Medication Administration Record (MAR) failed to reveal evidence that the Mucinex was administered as ordered. The Mucinex was only administered twice on 4/20/2025 and not for three days as ordered. During a surveyor interview on 4/23/2025 at 11:03 AM with Registered Nurse (RN), Staff A, she acknowledged that the Mucinex was administered for only one day and not the three days as ordered. During a surveyor interview on 4/23/2025 at 12:03 PM with the Director of Nursing Services (DNS), she acknowledged that the resident only received the medication for one day and not the three days as ordered. 2. Record review revealed Resident ID #63 was admitted to the facility in November of 2024 with diagnoses including, but not limited to, high blood pressure and atrial fibrillation (an irregular heart rhythm). Record review revealed an order dated 11/18/2024 for Metoprolol Succinate extended release, 25 mg tablet by mouth daily in the morning. Record review of the March and April 2025 MARs revealed the resident's blood pressure was obtained prior to the administration of the Metoprolol. Further review of the March and April MARs revealed the Metoprolol was held on the following dates with the following blood pressures: - 3/1/2025, 91/64 (a normal blood pressure is 120/80) - 3/5/2025, held without a blood pressure documented - 3/6/2025, held without a blood pressure documented - 3/13/2025, 92/54 - 3/19/2025, 92/52 - 3/25/2025, 98/68 - 4/2/2025, 92/65 - 4/16/2025, 97/57 Further review of the physician's order failed to indicate that the medication was to be held based on the resident's blood pressure readings. Record review of the progress notes failed to reveal evidence that the provider was notified on the above dates when the Metoprolol was held. During a surveyor interview on 4/23/2025 at 2:13 PM with RN Staff B, she acknowledged that she held the Metoprolol on 3/1, 3/13, 3/19, 3/25, 4/2 and 4/16. Additionally, she was unable to provide evidence that the provider was notified of the resident's blood pressures and that the medication was held. During an interview on 4/23/2025 at approximately 3:00 PM with the DNS, she was unable to provide evidence that the provider was notified of the resident's blood pressures and that the Metoprolol was held on 3/1, 3/5, 3/6, 3/13, 3/19, 3/25, 4/2 and 4/16/2025. 37158

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure resident's records are accurate, complete and readily accessible for 1 of 1 resident reviewed with a physician's order for one to one (1:1) supervision, Resident ID #48. Findings are as follows: Record review of a facility reported incident received by the Rhode Island Department of Health on 4/15/2025 alleges that on 4/15/2025, a staff member witnessed Resident ID #48 touching the top of Resident ID #88's head. Additionally, the report revealed that Resident ID #88 pushed Resident ID #48's arm away from his/her head and then grabbed it. Record review revealed Resident ID #48 was admitted to the facility in March of 2025 with diagnoses including, but not limited to, dementia and anxiety. Record review of an additional facility reported incident received by the Rhode Island Department of Health on 4/17/2025 revealed on 4/17/2025, Resident ID #48 was seen hitting another resident, Resident ID #28, on his/her forehead. Record review revealed a physician's order dated 4/17/2025 that states in part, 1:1 supervision until seen and cleared by behavioral health services every shift for resident-to-resident altercation. Record review completed on 4/22/2025 failed to reveal evidence that the resident was seen by behavioral health services after 3/17/2025. Record review of the April 2025 Medication Administration Record revealed staff documented that 1:1 supervision was completed every shift from 4/17/2025 through 4/22/2025 on the first shift. During surveyor observations of Resident ID #48 revealed s/he was without 1:1 supervision on the following dates and times: -4/21/2025 at 10:03 AM and 12:53 PM -4/22/2025 a continuous observation from 10:00 AM through 12:00 PM During a surveyor interview on 4/22/2025 at 12:03 PM with Registered Nurse (RN), Staff C, she revealed that she was unaware of the 1:1 supervision order. Additionally, she indicated that she inaccurately documented that she provided the resident 1:1 supervision, when in fact she did not. During a surveyor interview on 4/23/2025 at 10:41 AM and at 3:30 PM with the Director of Nursing Services (DNS), in the presence of the Regional Director of Clinical Services, she indicated that the resident was seen by the consultant Behavioral Health Advanced Practice Registered Nurse (APRN) and acknowledged that the documentation was not in the medical record. Although the DNS indicated that the resident was seen multiple times by the APRN, the record review failed to reveal evidence that the resident was seen by the APRN after the incidents on 4/15 and 4/17/2025. 21613

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to Enhanced Barrier Precautions (EBP; refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO] that employs targeted gown and glove use during high contact resident care activities), Resident ID #s 22, 55, 215 and 367. Findings are as follows: Review of a facility policy titled, .Enhanced Barrier Precautions last revised December of 2024 states in part, .1. Enhanced Barrier Precautions (EBP) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to resident's . 2. Enhanced barrier precautions apply when: a. A resident is infected or colonized [a group of microorganisms that may not make the infected person sick but may still be spread to others] with a CDC-targeted MDRO, but does not have a wound or indwelling devise, and does not have secretions or excretions that cannot be covered or contained; b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained . 5. Indwelling medical devices include .urinary catheters . 6. Examples of secretions or excretions include wound drainage .or other discharges from the body that cannot be contained and pose an increased potential for extensive environmental contamination and risk of transmission . 7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room) . 8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include . e. transferring . h. prolonged, high-contact with items in the resident's room, with resident's equipment, or with resident's clothing or skin . i. device care or use .urinary catheter . 17. Signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE required . 1. Record review revealed Resident ID #22 has an indwelling urinary catheter, is diagnosed with Extended-Spectrum Beta-Lactamases in the urine (ESBL- a multidrug resistant organism) and is on EBP. During a surveyor observation on 4/21/2025 at 12:20 PM, EBP signage was affixed to the resident's doorway and a bin containing PPE was outside of the room. The Director of Nursing Services (DNS) and the Admissions Director assisted Resident ID #22 with a transfer from his/her bed to a chair in the resident's room without wearing a gown or gloves. The Admissions Director then took the resident's pillow off of his/her bed and placed it behind the resident's back. Additionally, the DNS handled the resident's urinary drainage bag with her bare hands, moving it from the side of the bed to the resident's walker. During a survey interview on 4/21/2025 at 12:25 PM with the Admissions Director, she acknowledged that she did not wear a gown and gloves to transfer the resident as outlined on the EBP sign on the resident's door. During a surveyor interview on 4/22/2025 at 4:18 PM with the DNS, she acknowledged that the resident is on EBP and that she did not wear a gown or gloves when transferring the resident and handling the urinary drainage bag. 2. Record review revealed Resident ID #55 has a chronic wound and is on EBP. During a surveyor observation on 4/23/2025 at 10:43 AM, EBP signage was affixed to the resident's doorway and a bin containing PPE was outside of the room. The housekeeper, Staff D, was observed entering the residents' room without a gown, wearing only gloves and carrying a spray bottle. Staff D removed multiple personal items from each of the resident's bedside tables, he then sprayed and wiped down each table. Staff D continued to clean the residents' sink, countertop and mirror before exiting the room. Staff D removed his gloves and failed to perform hand hygiene. He then re-entered the residents' room with a mop and solution without donning any PPE and continued to mop the floor. Furthermore, he was observed emptying the resident's wastebasket before exiting the room. During a surveyor interview immediately following the above observation, Staff D was unable to explain what PPE he should have worn. 3. Record review revealed Resident ID #367 has ESBL in his/her urine and is on EBP. During a surveyor observation on 4/23/2025 at 10:46 AM, EBP signage was affixed to the resident's doorway and a bin containing PPE was outside of the room. A phlebotomist from the facility's contracted laboratory company, was observed kneeling on the floor of the resident's room while obtaining the resident's blood. The phlebotomist was observed wearing gloves only, but no gown. During a surveyor interview immediately following the above observation, the phlebotomist acknowledged that she was not wearing a gown during her interaction with the resident. During a surveyor interview on 4/23/2025 at 11:54 AM with the DNS, she was unable to explain why Staff D and the phlebotomist did not wear the appropriate PPE while in the residents' rooms who are on EBP. 46118

Based on record review and staff interview, it has been determined that the facility failed to reconcile all pre-discharge medication orders with the resident's post-discharge medication orders, for 1 of 3 residents reviewed relative to discharge from the facility, Resident ID #2. Findings are as follows: Record review revealed the resident was admitted to the facility in September of 2024 with diagnoses including, but not limited to, polymyalgia rheumatica (an inflammatory disorder that causes pain), osteoarthritis and cervical disc disorder (injuries to the discs between the vertebrae). Further review revealed the resident was discharged to his/her home on 10/13/2024. Record review of the active physician's orders on the day of the resident's discharge on 10/13/2024, revealed the following: - Acetaminophen (a medication prescribed to treat pain) 1000 mg (milligrams), give 1000 mg three times a day. - Cholecalciferol (a supplement prescribed to treat vitamin D deficiency) 1000 units, give 1 tablet once daily. - Gabapentin (a medication prescribed to treat nerve pain) 100 mg, give 1 capsule by mouth two times a day. Record review of the resident's, Rhode Island Health Continuity of Care (COC) Form completed for at the time of the resident's discharge and signed by the discharging nurse and the resident's representative on 10/13/2024, revealed the following physician's orders: - Acetaminophen 500 mg, 1 tablet three times a day. - Cholecalciferol 1000 units, give 1 tablet twice daily. - Gabapentin 100 mg, give 1 capsule once daily. During a surveyor interview with the Director of Nursing Services on 11/27/2024 at 1:46 PM, she acknowledged that the above-mentioned discharge medications were transcribed incorrectly on the resident's COC.

Based on record review and staff interview, it has been determined that the facility failed to ensure that the results of all alleged abuse investigations are reported in accordance with State law, including to the State Survey Agency (Rhode Island Department of Health; RIDOH), within 5 working days of the incident for 5 of 10 facility reported incidents (FRI) reviewed. Findings are as follows: 1. Review of a FRI submitted to the RIDOH on 7/12/2024, failed to reveal evidence that the results of the facility's investigation were submitted to RIDOH within 5 working days of the incident. 2. Review of a FRI submitted to the RIDOH on 7/12/2024, failed to reveal evidence that the results of the facility's investigation were submitted to RIDOH within 5 working days of the incident. 3. Review of a FRI submitted to the RIDOH on 7/24/2024, failed to reveal evidence that the results of the facility's investigation were submitted to RIDOH within 5 working days of the incident. 4. Review of a FRI submitted to the RIDOH on 8/9/2024, failed to reveal evidence that the results of the facility's investigation were submitted to RIDOH within 5 working days of the incident. 5. Review of a FRI submitted to the RIDOH on 8/20/2024, failed to reveal evidence that the results of the facility's investigation were submitted to RIDOH within 5 working days of the incident. During a surveyor interview on 9/3/2024 at 1:00 PM with the Administrator and the Director of Nursing Services, they acknowledged that results of the five above-mentioned FRI investigations were not reported to RIDOH, within 5 working days of the incident, as required.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 4 of 5 residents reviewed for respiratory care, Resident ID #s 4, 20, 105, and 112. Findings are as follows: Record review of a facility policy titled, Oxygen Administration states in part .review the physician's order for this procedure .review resident's care plan to assess needs of the resident . Additional review of the policy under the section titled documentation states in part, .date and time procedure was performed .name and title of the individual who performed the procedure .rate of oxygen flow, route, and rationale . 1. Record review revealed Resident ID #4 was admitted to the facility in July of 2022 with diagnoses including, but not limited to, hypertension, and diabetes. Record review of the resident's May 2024 Treatment Administration Record (TAR) revealed an order dated 6/6/2023 for oxygen 2-4 liters/minute via nasal cannula (a tubing used to deliver oxygen) to maintain oxgen saturation greater than 90% (normal range is 95%-100%) every 8 hours as needed. During surveyor observations on the following dates and times, the resident was observed on 1 liter of oxygen instead of 2-4 liters as ordered: -5/6 at 10:48 AM -5/7 at 9:04 AM -5/8 at 8:45 AM Further record review of the TAR for May failed to reveal evidence that the resident received the 2-4 liters of oxygen on the above-mentioned dates and times, as ordered and per the facility's policy. During a surveyor observation and interview with Licensed Practical Nurse (LPN), Staff A on 5/8/2024 at approximately 9:00 AM, she acknowledged the resident was receiving 1 liter of oxygen instead of 2-4 liters, as ordered. 2. Record review revealed Resident ID #20 was admitted to the facility in September of 2023 with diagnoses including, but not limited to, pneumonia and anxiety. Record review of the resident's May 2024 TAR revealed an order dated 5/3/2024 for intermittent oxygen at 2-4 liters/minute via nasal cannula for oxygen saturation greater than 93% every 24 hours as needed. During surveyor observations on the following dates and times, the resident was observed on 1 liter of oxygen instead of 2-4 liters as ordered: -5/6 at 10:26 AM -5/6 at 1:53 PM -5/7 at 9:04 AM -5/8 at 8:50 AM Further record review of the TAR for May failed to reveal evidence that the resident received the 2-4 liters of oxygen on the above-mentioned dates and times, as ordered and per the facility's policy. During a surveyor interview with LPN, Staff A on 5/8/2024 at 9:03 AM, she acknowledged that the resident was on 1 liter of oxygen instead of 2-4 liters, as ordered. 3. Record review revealed Resident ID #105 was admitted to the facility in April of 2024 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD, a lung disease that blocks airflow that makes it difficult to breath) and acute respiratory failure. Record review of the resident's May 2024 TAR revealed an order dated 4/30/2024 for oxygen 1 liter/minute via a nasal cannual as needed for comfort and shortness of breath. During surveyor observations on the following dates and times, the resident was observed on 2 liters of oxygen instead of the 1 liter as ordered: -5/6 at 9:48 AM -5/6 at 9:50 AM -5/7 at 11:25 AM -5/7 at 11:51 AM Further record review of the TAR for May failed to reveal evidence that the resident received the 1 liter of oxygen on the above-mentioned dates and times, as ordered and per the facility's policy. During a surveyor interview with the Regional Nurse on 5/8/2024 at 12:30 PM, she acknowledged the staff had failed to document the resident had received oxygen on the above-mentioned dates and times as observed by the surveyor. Additionally, she revealed that she would expect the staff to document each time oxygen is administered to a resident as per the facility's policy. 4) Record review revealed Resident ID #112 was admitted into the facility in April of 2024 with diagnosis including, but not limited to, chronic obstructive pulmonary disease. Record review of the resident's May 2024 TAR revealed an order dated 4/10/2024 to titrate (adjust the oxygen based on the resident's needs) continuous oxygen as needed to maintain oxygen saturation greater than 95% every 8 hours. Record review of the above-mentioned order failed to reveal evidence of a flow rate of the liter of oxygen to be administered and titrated to the resident. During surveyor interviews on 5/8/2024 at 10:04 AM and at 11:38 AM with the Director of Nursing Services (DNS), she indicated that she would expect the oxygen order to include the flow rate that should be administered to the resident. Additionally, the DNS indicated that she would expect the staff to administer oxygen to the residents as ordered, and that each time oxygen is administered, the staff is expected to document the administration, as per the facility's policy. 47939 49184

Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident receives care to prevent accidents for 1 of 7 residents reviewed for falls, Resident ID# 74. Findings are as follows: Record review revealed the resident was admitted to the facility in July of 2018 with diagnoses that include but are not limited to Alzheimer's disease, contracture of the right and left hands, cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels), and dementia. Review of a quarterly minimum data set assessment dated [DATE] revealed the resident is rarely or never understood and is totally dependent of two or more staff for bed mobility which includes moving to and from lying position, turning side to side, and positioning body while in bed. Review of a fall risk assessment dated [DATE] indicated s/he was a high fall risk. Review of a safe patient handling tool dated 11/24/2021 revealed the following: -resident's level of cooperation/comprehension is unpredictable or varies not cooperative, or unable to follow simple commands. -resident's ability to reposition in bed: side-to-side, up in bed, cannot assist. Use full body sling lift and 2 or more caregivers. Review of a care plan with a problem start date of 9/9/2019 revealed the resident is at risk for falls related to history of falls, leans, is non-verbal and has decreased mobility. The evaluation note on the care plan dated 10/27/2021 revealed the resident sustained an unwitnessed fall from bed, rolled from bed, care was being performed and was interrupted. Staff education on use of air mattress and positioning for safety. Additionally, a care plan dated 10/4/2019 revealed the resident has ADL (activities of daily living) functional loss and requires assist of two for bed mobility. Further review revealed an intervention dated 4/16/2020 to utilize safe patient handling techniques during mobility and repositioning. During an interview on 3/2/2022 at 11:19 AM with the Nursing Assistant (NA) Staff B, who was assigned to care for the resident, she revealed anyone on an air mattress requires two staff members to assist because when you turn them, the air distributes and the bed becomes uneven. She further revealed she has always known the resident to be totally dependent on staff for all care, that his/her upper extremities are contracted and that the resident is unable to assist with any ADLs and uses a mechanical lift for transfers. Further review revealed a progress note dated 1/12/2022 which stated in part, At approximately 1545 CNA [nursing assistant] alerted this writer that resident rolled off bed during care. This writer found resident down on floor next to bed with laceration to forehead (R [right] side). Direct pressure applied to wound. call placed to 911 .NP [nurse practitioner] .family, ADNS [assistant director of nursing] notified of fall, injury, and transfer .resident to [name redacted] Hospital ER [emergency room ] for evaluation. Review of a hospital discharge summary dated 1/12/2022 revealed the resident was seen after the fall for a repair of a head laceration. During an interview on 3/2/2022 at 3:22 PM with NA, Staff C, he revealed he was providing care to the resident on 1/12/2022 when s/he rolled out of bed. He further revealed that he turned the resident toward him and the air mattress shifted, and the resident rolled toward him, and rolled out of the bed. Additionally, he revealed he called the nurse immediately because the resident was bleeding. During an interview on 3/2/2022 at 12:59 PM with Registered Nurse (RN), Staff D, who was the nurse who cared for the resident during the day on 1/12/2022, she revealed from her understanding, when Staff C turned the resident, the air mattress deflated, and the resident rolled out of bed onto the floor. She revealed that she thought Staff C was alone, but was not certain. During an interview on 3/2/2022 at 3:41 PM with RN, Staff E, who was the nurse assigned to care for the resident at the time s/he rolled out of bed. She believes Staff C was alone at the time the resident fell out of bed. During an interview on 3/3/2022 at 3:05 PM with RN, Staff F, she revealed she was not the resident's nurse, but was working on the unit on 1/12/2022. She revealed she did not witness the incident, but was told Staff C was the only one in the room when the resident rolled out of bed. She further stated this is not the first time the resident has rolled out of bed. During an interview on 3/3/2022 at 3:24 PM with NA, Staff G, who was assigned as an NA on the unit where the resident resides on 1/12/2022. She revealed that Staff C was in the room when s/he rolled out of bed. She further stated she was not in the room at the time of the incident. During an additional interview with Staff B on 3/3/2022 at 3:16 PM, she revealed she was working on the unit but not assigned to care for the resident. She further revealed she was not present in the room at the time of the incident. During an interview with the MDS (Minimum Data Set) Nurse, Staff H, on 3/3/2022 at 1:01 PM, she stated, referring to the date of the incident, I was in the building, they called me, I went to educate .but I don't think the NA knew exactly what to do when the air mattress deflated, he didn't know about static [alternating pressure] air, he is not a seasoned NA, I educated him . During an interview with the Director of Nursing Services on 3/3/2022 at 12:25 PM she was unable to provide evidence that two staff members were present, caring for the resident, at the time the resident rolled out of the bed.