**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to keep a resident free from physical abuse for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 5/13/2025, revealed in part, that Resident ID #s 1 and 2 were sitting in the dining room, at opposite ends of a table, when Resident ID #2 walked over to Resident ID #1 and struck him/her in the face multiple times. Further review revealed both residents were immediately separated, Resident ID #1 was assessed for injury, with no injury noted, and Resident ID #2 was sent to the hospital for a geriatric psychiatric evaluation. Review of a policy titled, Abuse Prohibition last revised 1/17/2023 states in part, .It is the policy of this facility to ensure that all residents are treated with respect and dignity and that all residents are free from abuse .DEFINITIONS .Abuse: willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish and includes physical .Examples of abuse include but are not limited to .Physical-Hitting, punching . Record review revealed that Resident ID #1, the victim, was admitted to the facility in December of 2023 with a diagnosis including, but not limited to, dementia. Review of Resident ID #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating the resident has severely impaired cognition. Record review revealed that Resident ID #2, the perpetrator, was admitted to the facility in August of 2023 with a diagnosis including, but not limited to, dementia. Review of Resident ID #2's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 4 out of 15, indicating the resident has severely impaired cognition. Review of Resident ID #2's care plan revealed a focus area, last revised on 7/26/2024, which indicated the resident has a history of physical aggression related to his/her diagnosis of dementia and poor impulse control. An intervention includes, but is not limited to, I appear to be triggered by increased stimulation from my peers and become agitated, staff will encourage me to go to a quieter area. Record review for Resident ID #2 revealed a progress note dated 5/13/2025 at 5:11 PM, which states in part, Elder was sitting in the dining room with [his/her] peers, elder had no [signs or symptoms] of agitation or aggression when this writer saw elder approximately 5 [minutes] prior to incident. Staff report that [Resident ID #2] got up from [his/her] chair and walked over to another elder and struck other elder in the face multiple times causing other elder's glasses to fall off. Incident appeared to be unprovoked by other elder. At the time of the incident there was increased stimulation in the dining room and activity room and other elder was repeating phrases to [him/herself] which is normal .NP [Nurse Practitioner] aware of incident and elder to be sent out to geri-psych . Record review for Resident ID #1 revealed a progress note dated 5/13/2025 at 5:00 PM, which states in part, Elder was involved in an altercation with another elder this evening. [Resident ID #1] was sitting in a chair in the dining room across from other elder, [s/he] was calm but repeating mamma what do I do? Mamma where do I go. [His/her] repetition of phrases is per usual for elder, [s/he] was calm and the volume of [his/her] talking .was low. Other elder got out of [his/her] chair and walked over to [Resident ID #1], [s/he] struck [him/her] multiple times in the face and [Resident ID #1's] glasses fell off. Staff immediately intervened and elder's were separated. [Resident ID #1] was assessed for injury with no redness, bruising or swelling noted. Elder denies pain and has no non-verbal [signs or symptoms] of pain. [Resident ID #1] was assisted out of the dining room and into the activity room. [Resident ID #1] was in a pleasant mood once [s/he] arrived to the activity room and had no recollection of the incident when talking to this writer . Review of an assessment titled Skin Incident Report, for Resident ID #1, dated 5/14/2025, revealed the resident had a change in skin integrity due to the incident with Resident ID #2 on 5/13/2025. Further review revealed the following skin impairments: - right dorsal (the top) hand bruise measuring 0.3 centimeters (cm) X 0.3 cm - 2 bruises to his/her left forearm measuring 0.4 cm X 0.2 cm and 0.3 cm X 0.3 cm - 2 linear scratches to his/her right lower forearm measuring 1.5 cm X less than (<) 0.1 cm and 1.3 cm X < 0.1 cm Review of a witness statement, authored by Hospice Registered Nurse, Staff A, dated 5/13/2025, states in part, In the late afternoon of 5/13/25 I was taking a patient back into the dinning room. Upon my approach I heard two residents arguing and yelling loudly. When I entered the dinning room I saw [Resident ID #1] on a chair at one end of the table, [s/he] was facing me and turned slightly into the table. [Resident ID #2] was positioned at [Resident ID #1's] left back and side, [Resident ID #2] had one arm positioned down from [Resident ID #1's] shoulder and chest and with [his/her] other hand [s/he] was punching [Resident ID #1]. [Resident ID #2] knocked [Resident ID #1's] glasses askew. I said loudly 'no, no, no' and walked toward the scuffle. [Resident ID #2] stopped hitting [Resident ID #1] and went back to where [s/he] was sitting at the other end of the table. [Resident ID #1] continued to yell at [Resident ID #2] about [him/her] shutting up .Staff then came and removed [Resident ID #2] from the table. During a surveyor interview on 6/4/2025 at 2:43 PM, with Unit Manager, Staff B, she revealed that initially, no staff were present in the dining room when the incident occurred, as one had just left to assist with care. She revealed that Staff A entered the dining room and saw Resident ID #2 hitting Resident ID #1 in the face. She further revealed that the following day, a full skin assessment was completed on Resident ID #1, due to this incident, and the resident was noted to have bruises and scratches on his/her arms, indicating they were consistent with defensive marks. Further, she revealed that Resident ID #2 has been involved in previous resident to resident incidents and was being followed by psychiatric services. During a surveyor observation on 6/4/2025 at 3:10 PM, Resident ID #1 was observed sitting outside with his/her peers. When approached by the surveyor and Staff B, s/he appeared pleasantly confused and in good spirits. Additionally, s/he was unable to be interviewed due to his/her cognitive impairment. During a surveyor interview on 6/4/2025 at 3:23 PM, with the Director of Nursing Services, she revealed that Resident ID #2 has been involved in previous resident to resident incidents, with the last one occurring in August of 2024. She further revealed that Resident ID #2 has a history of behaviors and indicated that s/he was completely unprovoked during the resident-to-resident incidents. She further revealed that Resident ID #2 was admitted to the hospital for a geriatric psychiatric evaluation, following this incident, and the decision was made to not accept him/her back to the facility due to safety concerns. Additionally, she was unable to provide evidence that Resident ID #1 was kept free from abuse.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to following a physician's order for nutritional supplements, for 2 of 2 residents reviewed, Resident ID #s 6 and 54, and for 1 of 1 resident reviewed for blood pressure monitoring who is prescribed furosemide, (a medication used to reduce fluid), Resident ID #54. 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 physicians' orders unless they believe the orders are in error or would harm the clients. 1a. Record review revealed Resident ID #6 was admitted to the facility with diagnoses including, but not limited to, dementia and diabetes. Record review revealed the following physician's orders: -7/6/2024 house supplement 4 ounces (oz.), three times per day for weight loss -7/26/2024 Pro-Stat AWC, (a concentrated liquid protein) 30 milliliters (ML), one time per day for wound care During a surveyor observation of the medication administration task on 2/19/2025 at approximately 9:20 AM with Registured Nurse (RN) Staff A, she was observed administering Resident ID #6 his/her morning medications. Additionally, Staff A was not observed to administer his/her supplements at the time of the observation. Record review of the February 2025 Medication Administration Record (MAR) revealed the above-mentioned supplements were documented as being administered on 2/19/2025 by RN, Staff A. 1b. Record review revealed Resident ID #54 was admitted to the facility with diagnoses including, but not limited to, dementia, and hypertensive heart disease (a heart condition that is caused by high blood pressure) with heart failure. Record review revealed the following physician's orders: -1/31/2024 furosemide, 20 milligrams (MG), give three tablets (60 mg) one time per day and monitor the resident's blood pressure. -5/7/2024 Pro-Stat AWC, 30 ML's one time per day. During a surveyor observation of the medication administration task on 2/19/2025 at approximately 9:30 AM with RN, Staff A, she was observed administering the resident's furosemide. Additionally, Staff A, was not observed to administer the supplement nor obtain the resident blood pressure when administering his/her furosemide at the time of the observation. Additionally, record review of the MAR revealed the furosemide was documented as administered with a blood pressure reading for the scheduled 10:00 AM dose. Record review of the February 2025 MAR revealed that the Pro Stat was documented as being administered on 2/19/2025 by RN, Staff A. During a surveyor interview on 2/19/2025 at 10:56 AM with Staff A, she acknowledged that she did not administer the supplements as ordered to Resident ID #s 6 and 54. Additionally, she revealed that she did not obtain Resident ID #54's blood pressure when she administered his/her furosemide. Further, she acknowledged that she documented that the supplements were given, and the blood pressure was obtained. During a surveyor interview on 2/19/2025 at 11:44 AM with the Director of Nursing Services, she revealed it would be her expectation that the nurse would follow the physician's orders.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed, in accordance with professional standards for food service safety relative to the main kitchen, 3 of 3 kitchenettes and 4 of 4 [NAME] House kitchens observed. Findings are as follows: 1. Record review of the Rhode Island Food Code 2018 edition, Section 3-602.11 Food Labels states, .Label information shall include: (1) The common name of the food . Review of the facility's policy, food brought to residents from the outside, states in part, .the food must be clearly labeled with the resident's name and room number, the date the food was brought to the resident, and also the use by date .Resident and family should be informed that if the food is not consumed within 72 hours, it will be discarded for food safety concern . Additionally the policy reveals that if the food is not eaten within 72 hours the resident or family will be notified and the foods will be discarded by the nursing staff. During the initial tour of the main kitchen, 3 of 3 kitchenettes, and 4 of 4 [NAME] House kitchens on 2/17/2025 at 8:20 AM, in the presence of the Director of Dining Services, the following was revealed: - Walk in refrigerator in the main kitchen: 2 one-gallon zip lock style bags approximately half full, containing sliced lemon wedges with a discard date of 2/16/2025. - Walk in freezer in the main kitchen: 3 packages of 12 frozen waffles, 2 packages of 6 frozen bagels, 1 bag of frozen fish sticks not labeled or dated. - Hill Unit kitchenette: Resident food consisting of a paper plate in a zip lock style bag containing 3 cooked chicken legs, one small to-go style container containing cooked pasta in a red sauce, and a large to-go style container containing eggplant parmesan that did not indicate a discard or arrival date. - Cove Unit kitchenette: one gallon zip lock style bag, approximately half full containing cut lemon wedges, without a label or a discard date. - [NAME] House #19 kitchen: a Rubbermaid style container, approximately ½ quart in size containing diced tomatoes, two packages of 12 frozen waffles, a half-gallon container of ice cream ¾ full with a substantial amount of freezer burn, without a label or a discard date. One unopened package of 12 english muffins with a sell by date of January 29th. - [NAME] House #21 kitchen: one opened package of 4 frozen chicken patties, without a label or a discard date. During a surveyor interview following the above observations with the Director of Dining Services, he acknowledged the above-mentioned findings. He further indicated that the above-mentioned items should have been labeled, dated, and discarded, as indicated in the facility food service policy and per the regulations. 2. Review of The Rhode Island Food Code 2018 Edition 4.601.11 reads in part, .equipment food contact surfaces .shall be clean to sight . During the initial tour of the main kitchen, 3 of 3 kitchenettes, and 4 of 4 [NAME] House kitchens on 2/17/2025 at 9:54 AM, in the presence of the Director of Dining Services, the following was revealed: - Bay Unit kitchenette: the microwave that is used for residents was observed with an accumulation of a dried light brown matter splattered on the inside of the glass door, along the inside wall, and on the glass turn plate. - [NAME] House #15: the freezer drawer below the refrigerator in the pantry, revealed an accumulation of food particles and debris including tortellini pasta on the bottom. - [NAME] House #17: the microwave that is used for the residents revealed an accumulation of brown matter, scattered on the inside of the glass door and on the ceiling. - [NAME] House #21: the microwave that is used for the residents revealed an accumulation of a greasy residue scattered on the inside of the glass door, on the ceiling, and on the glass turn plate. During a surveyor on interview on 2/17/2025 at approximately 9:35 AM with the Director of Dining Services, he acknowledged the above-mentioned observations. He indicated that the Shahbaz staff (nursing assistants who work in the [NAME] Houses that provide comprehensive direct care to those residents) for each [NAME] House are responsible for cleaning the microwaves, and that there is a weekly cleaning schedule in place with a designated day of Tuesday. Additionally, he indicated it would be his expectation that the microwaves be cleaned according to the weekly cleaning schedule, and as needed.

Based on record review and staff interview, it has been determined that the facility was not being administered in a manner that enabled it to utilize resources effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being of each resident related the elopement of Resident ID #1. This failure resulted in an Immediate Jeopardy for F 689. Findings are as follows: Record review of a facility policy titled Missing Resident Policy states in part, Purpose: To provide direction to staff when a resident is determined to be missing or has eloped. Notify the Person in charge and/or charge nurse. Determine the time that the resident was discovered missing and when and where he/she was last seen .Check with other staff. Contact family to ask them if the resident is with them. If unable to determine where the resident is, notify other staff in the building and promptly search the facility and premises .If missing resident is not found following and expedite search (approximately 30 minutes), call 9-1-1 and provide Name of the resident, Date/time and location resident was last seen . Record review revealed that on 1/2/2025 at approximately 4:00 AM, Resident ID #1 was observed by a passerby sitting down in a busy main roadway, unsupervised by staff. The resident was taken to the police station where emergency medical services were called to transport the resident to the hospital. Additionally, the temperature at the time was approximately 37 degrees Fahrenheit with intermittent snow showers. Review of video footage dated 1/2/2025 at 2:31 AM revealed Resident ID #1 was wandering around the main entrance of an Assisted Living Residence located 0.2 miles from the facility, without a coat or shoes on. During a surveyor interview on 1/14/2025 at 8:13 AM with Staff B, he stated that he was notified that Resident ID #1 was noted to be missing at approximately 6:00 AM on 1/2/2025. Additionally, he revealed that he looked for the resident for 10 to 15 minutes. He does not remember anyone assisting him in his search for the missing resident. At this time Staff B contacted the on call Manager, Registered Nurse (RN), Staff F at approximately 6:20 AM, who instructed him to read an education book in order to follow the appropriate steps for the missing resident policy, which was located in an office. Staff B revealed he was unable to locate the book, so Staff F proceeded to read him the steps on what to do over the telephone. During surveyor interviews on 1/13/2025 at 1:15 PM and 1:42 PM with the Director of Nursing Services (DNS), she revealed that Resident ID #1 was last seen at approximately 8:00 PM on 1/1/2024. Additionally, she revealed that on call manager, Staff F was notified at 6:20 AM on 1/2/2025 that the resident was missing and that she was notified approximately two minutes later. Additionally, she revealed that she arrived at the facility was at approximately 7:25 AM. Furthermore, she revealed that Staff E contacted Resident's ID #1's family at approximately 7:15 AM who informed her that the resident was in the hospital. She furthermore acknowledged that the resident was unaccounted for by the facility for an extended period of time, approximately 10 hours after she was last seen by the second shift staff. Lastly she acknowledged that the staff did not properly follow the elopement policy and failed to notified family and the police timely. During a surveyor interview on 1/3/2025 at approximately 12:00 PM, with the Administrator she acknowledged that the resident eloped from the facility unsupervised even though there were two alarmed doors located on the 1st and 2nd floors that s/he would have to have activated when s/he left the facility. Additionally, she revealed that staff had not responded to any alarms on the night shift of 1/1-1/2/2025. During a subsequent interview with the Administrator on 1/6/2025 at 9:14 AM, she revealed that the alarms on the doors had been turned off by staff. Furthermore, she revealed that facility would be placing additional alarms on the doors and the keys to deactivate them will remain with the nurses on the unit, so that staff will unable to turn them off. During an additional surveyor interview on 1/13/2025 at 4:56 PM with the Administrator, she acknowledged that Resident ID #1 was unaccounted for an extended period and left the facility unsupervised and was seen on another facilities video footage at 2:31 AM. In addition, she acknowledges that facility staff did not follow the facility's policy for a missing resident. She furthermore stated that during this incident, everything that could go wrong, went wrong. Cross reference F689

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview it has been determined that the facility failed to protect and keep residents free from physical abuse relative to an incident that occurred between Resident ID #1 and #2, resulting in a skin tear for Resident ID #2. Findings are as follows: Review of a facility policy titled, Abuse prohibition states in part, .It is the policy of this facility to ensure that all residents are treated with respect and dignity and that all residents are free from abuse .Abuse: Willful infliction of injury .resulting in physical harm .Examples of abuse include but are not limited to the following: Physical - Hitting, punching, pinching, kicking . Record review of a facility reported incident of resident-to-resident abuse was submitted to the Rhode Island Department of Health on 9/17/2024. The report indicates that Resident ID #2 was being assisted out of the chair to be moved when Resident ID #1 bent over and pinched Resident ID #2 on the leg causing a skin tear. Record review revealed Resident ID #2, (the victim), was readmitted to the facility in June of 2021 with diagnoses including, but not limited to, Alzheimer's disease and type II diabetes. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating severely impaired cognition. Review of a progress note dated 9/11/2024 at 4:09 PM revealed, Resident ID #1 told Resident ID #2 not to touch his/her food. Additionally, it revealed that Resident ID #2 was being removed from the table when Resident ID #1 reached under the table and pinched Resident ID #2 in the leg, causing a skin tear. Review of a physician's order dated 9/13/2024 revealed, clean Resident ID #2's shin skin tear with normal saline, pat dry, and apply xeroform (wound treatment) to wound bed and cover with a foam dressing, every 3 days. Review of the September 2024 Treatment Administration Record revealed, Resident ID #2's wound was treated from 9/13/2024 through 9/28/2024, a duration of 22 days. Record review revealed Resident ID #1, (the perpetrator) was admitted to the facility in August of 2022 with a diagnosis including, but not limited to, dementia. Review of a quarterly MDS assessment dated [DATE], revealed a BIMS score of 3 out of 15, indicating severely impaired cognition. Review of a progress note dated 9/11/2024 at 4:09 PM revealed, Resident ID #1 told Resident ID #2 not to touch his/her food. Additionally, it revealed that Resident ID #2 was being removed from the table when Resident ID #1 reached under the table and pinched Resident ID #2 in the leg, causing a skin tear. During a surveyor interview on 10/3/2024 at 8:24 AM with Nursing Assistant, Staff A, she revealed Resident ID #1 told Resident ID #2 not to touch his/her food. She further revealed that when staff intervened with the family to separate Resident ID #2 from Resident ID #1, Resident ID #1 reached under the table and pinched Resident ID #2. During a surveyor interview on 10/3/2024 at 9:54 AM with the Unit Manager, she revealed Resident ID #2 attempted to touch Resident ID #1's food and that the residents were being separated. She revealed that during staff and family intervening to separate the resident's, Resident ID #1 reached under the table and pinched Resident ID #2, which resulted in a skin tear on his/her leg that required a treatment. A surveyor interview was attempted on 10/3/2024 at 11:13 AM with Resident ID #2 but the resident was unable to recall the above-mentioned incident due to impaired cognition. A surveyor interview was attempted on 10/3/2024 at 11:50 AM with Resident ID #1 but the resident was unable to recall the above-mentioned incident due to impaired cognition. During surveyor interviews on 10/3/2024 at 9:31 AM and approximately 1:30 PM with the Director of Nursing Services, she acknowledged that Resident ID #1 pinched Resident ID #2's leg resulting in a skin tear. Additionally, she was unable to provide evidence that Resident ID #2 was kept free from physical abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on 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 and the comprehensive care plan relative to 1 of 1 resident reviewed with a skin tear, Resident ID #2. Findings are as follows: Record review revealed Resident ID #2 was readmitted to the facility in June of 2021 with diagnoses including, but not limited to, Alzheimer's disease and type II diabetes. Review of a progress note dated 9/11/2024 revealed, a resident reached under a table and pinched Resident ID #2 in the leg, resulting in a skin tear. Review of a physician's order dated 9/13/2024 revealed, clean Resident ID #2's shin skin tear with normal saline, pat dry, and apply xeroform (wound treatment) to wound bed and cover with a foam dressing, every 3 days. Review of the September 2024 Treatment Administration Record revealed, Resident ID #2's wound was treated from 9/13/2024 through 9/28/2024, a duration of 22 days. Review of a skin assessment dated [DATE] revealed, the resident had a skin tear with the following instructions related to documentation which should include, the type of wound (abrasion, pressure, skin tear, etc.), measurements of wound length by width by depth, odor, edema, edges, type of tissue in the wound bed, evidence of infection, pain, drainage type and amount, and surrounding skin. Record review failed to reveal evidence at the time of the skin tear or during the following skin assessment on 9/16/2024 that the wound documentation in the medical record included the size of the wound, wound edges, and the wound bed, shape, and the condition of surrounding tissue, per the regulation. During a surveyor interview on 10/3/2024 at 12:40 PM with the Unit Manager, she revealed that the wound was a flap of skin that was pinched and that the wound did bleed at the time of the initial injury. Furthermore, she acknowledged that the residents wound was not measured and there was no identifying characteristics of the wound documented. A surveyor interview was attempted on 10/3/2024 at 11:13 AM with Resident ID #2 but the resident was unable to recall the the above-mentioned incident related to impaired cognition. During surveyor interviews on 10/3/2024 at 9:31 AM and approximately 1:30 PM with the Director of Nursing Services, she acknowledged that there was no documentation regarding Resident ID #2's skin tear on 9/11/2024 or 9/16/2024.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that a resident receives incontinence care per the resident's plan of care for 1 of 3 residents reviewed for incontinence care, Resident ID #196. Findings are as follows: Record review revealed the resident was admitted to the facility in February of 2024 with a diagnosis including, but not limited to, dementia. Record review of an admission Minimum Data Set Assessment revealed the resident's Brief Interview for Mental Status score was 3 of 15, indicating severe cognitive impairment. Record review of the resident's current care plan dated 2/29/2024 revealed .a decline in ADLS [Activities of Daily Living] and mobility . with interventions including, but not limited to; .I need assist with toileting . Further review of the care plan revealed, .incontinent of bladder and need assistance with toileting . with interventions including, but not limited to, .Offer toileting routinely on rounds .Provide routine incontinent care on rounds . During a surveyor observation of the resident on 3/5/2024 from 9:35 AM through 2:20 PM (approximately 5 hours) revealed the resident sitting in his/her wheelchair either in the dining room or in the activity room. During this observation period, toileting or incontinence care was not provided to the resident. An additional observation of the resident on 3/6/2024 from 11:01 AM through 2:45 PM (approximately 3 and ½ hours) revealed the resident sitting in his/her wheelchair either in the dining room, hallway or activity room. During this observation period, toileting or incontinence care was not provided to the resident. During a surveyor interview with the Unit Manager, Registered Nurse, Staff A, on 3/6/2024 at 2:20 PM, she revealed that the facility does not have a policy or procedure relative to toileting or providing incontinence care. Staff A further revealed that staff are expected to toilet the residents frequently, at least twice per shift, before lunch and after lunch. During a surveyor interview with the Director of Nursing Services on 3/6/2024 at 3:02 PM, she revealed that the facility does not have a policy or procedure relative to toileting or providing incontinence care. Additionally, she indicated that staff should provide incontinence care to residents at least every 2 hours.

Based on record review and staff interview, it has been determined that the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of the clinical reference ranges in a timely manner for 1 of 2 residents reviewed relative to labratory services, Resident ID #89. Findings are as follows: Record review revealed the resident was admitted to the facility in October of 2019 with a diagnosis including, but not limited to, Alzheimer's disease. Record review of a progress note dated 2/28/2024 revealed the resident was noted to have an increased body temperature of 99.8 degrees Fahrenheit (a potential symptom of an infection). Record review revealed a urine sample was obtained for a culture and sensitivity test on 2/29/2024. Review of the Lab Results Report dated 3/2/2024 revealed the results of the urine culture and sensitivity indicated that the resident was positive for a urinary tract infection (UTI) and was Reported to the facility on 3/2/2024 at 12:17 PM. Record review revealed the results of the urine culture and sensitivity were not reviewed by staff until 3/3/2024 at 11:17 PM, approximately 35 hours after the results were Reported to the facility. Additional record review revealed a physician was notified of the above results and a new order was obtained on 3/4/2024 at 12:17 AM for Levofloxacin (antibiotic) oral tablet 250 milligrams, administer once a day for 3 days. During a surveyor interview with a Certified Medication Technician, Staff B, on 3/4/2024 at 2:27 PM, she revealed that she administered the first dose of the above mentioned medication to the resident that morning at 10:20 AM (almost 2 days after the results of the urine culture and sensitivity were Reported). During a surveyor interview via telephone with the Lab Client Services Supervisor, on 3/6/2024 at 1:49 PM, she revealed the results of the urine culture and sensitivity were finalized on 3/2/2024 and the results were reported via electronic medical record to the facility on 3/2/2024 at 12:17 PM. During a surveyor interview with the Unit Manager, Registered Nurse, Staff A, on 3/6/2024 at 2:18 PM, she revealed that staff are expected to review the lab results at least every shift and report the results to the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist in a timely manner. During a surveyor interview with the Director of Nursing Services on 3/6/2024 at 3:01 PM, she revealed that the facility does not have a policy for reporting lab results to the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist. She further revealed she would expect that staff review resident's lab results at least every shift and report the results to the ordering physician within 2 hours.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive and consume fluids in the appropriate form for 1 of 1 resident observed with a dietary order for nectar thickened fluids, Resident ID #67. Findings are as follows: Review of a document titled, Thickening Liquids Information Sheet, revealed in part, .Nectar-thick but pourable like syrup, consistency of a milk shake, or V-8 juice .Mixing Starch-based Thickeners .Thick & Easy .1. Determine the number of ounces of the liquid that needs thickening and how much thickener you need to add, which is located on the can .Some liquids might need a little bit more or less of thickener to reach the desired consistency so check it before drinking or serving . Review of the resident's record revealed s/he was admitted to the facility in April of 2023 with diagnoses including but not limited to, dementia and dysphagia (difficulty swallowing). Review of a physician's order dated 2/22/2024 revealed s/he is to be provided with nectar thick consistency fluids and no straws as s/he is on aspiration precautions (practices to prevent food or fluids from getting into the airway). Review of the care plan, revised on 2/22/2024, revealed that s/he is to be provided with nectar thick fluids as ordered, is on aspiration precautions, and was treated for pneumonia on 2/15/2024. During a surveyor observation of the resident in his/her room on 3/4/2024 at 2:06 PM, revealed that s/he was sitting in the bedside chair wearing a nasal cannula (a device used to deliver supplemental oxygen), with his/her mouth open and breathing rapidly. S/he indicated to this surveyor that s/he just returned from the dining room and was tired. This surveyor instructed him/her to press the call light and Nursing Assistant, (NA), Staff C, entered the room. As this surveyor was interviewing NA Staff C, NA, Staff D, entered the room and handed Staff C a clear plastic cup with a lid and a straw that contained fluid. Staff C then handed this cup to the resident to drink. Licensed Practical Nurse (LPN), Staff E, then entered the room and when asked by the surveyor about the fluids the resident was drinking in the cup she indicated that the resident cannot have straws and that the fluid in the cup was not thickened to the appropriate nectar thick consistency. Additionally, she indicated that her expectation would be that the resident's dietary order would be followed. During a surveyor interview on 3/4/2024 at 2:20 PM with Staff D, it was indicated that she used Thick & Easy thickener to prepare the drink for the resident. Additionally, she acknowledged that she did not add the appropriate amount of thickener for nectar thick consistency as ordered. Additionally, she acknowledged a straw was provided with the drink. During a surveyor interview on 3/6/2024 at 3:25 PM with the Director of Nursing Services, she was unable to provide evidence that the physician's order was followed regarding nectar thick fluids and no straws.

Based on record review and staff interview, it has been determined that the facility failed to provide required in-service training, including dementia management training for 4 of 7 staff members reviewed, Staff D, J, K, and L. Findings are as follows: Review of the employees' annual in-service education on 3/6/2024 at approximately 10:00 AM with the Director of Nursing Services (DNS) and the Education and Employee Health, Registered Nurse, failed to reveal evidence that Staff D, J, K, and L, had annual required dementia management training. During an interview with the DNS immediately following the above review, she indicated that she would expect the required dementia management in-service training to have been completed annually.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed, in accordance with professional standards for food safety relative to the main kitchen and 3 of 3 kitchenettes, and 4 of 4 [NAME] House kitchens. Findings are as follows: 1. Record review of the Rhode Island Food Code 2018 edition, Section 3-602.11 Food Labels states, .(B) Label information shall include: (1) The common name of the food . Review of the facility's policy, food brought to residents from the outside, states in part, .the food must be clearly labeled with the resident's name and room number, the date the food was brought to the resident, and also the use by date .Resident and family should be informed that if the food is not consumed within 72 hours, it will be discarded for food safety concern . Additionally the policy reveals that if the food is not eaten within 72 hours, refrigerated or at room temperature, resident or family will be notified and the foods will be discarded by nursing staff. A. During the initial tour of the main kitchen on 3/4/2024 at 9:31 AM, in the presence of the Cook, Staff I, and the Culinary Director, the following was revealed: 1. Walk in refrigerator: a plastic bag of string beans, not labeled or dated and 1 container of strawberries that were noted to have a fuzzy covering. 2. Walk in freezer: an opened plastic bag of uncooked chicken, not labeled or dated. During a surveyor interview with the Staff I, following the above observations, she revealed the above items should be labeled and dated. B. A surveyor observation on 3/4/2024 at 1:10 PM of the Hill Unit kitchenette revealed a refrigerator containing 4 chocolate mighty shakes. The instructions on the carton states, store frozen thaw at or below 40 F [Fahrenheit] use thawed products within 14 days keep refrigerated. The above-mentioned shakes did not indicate a date when thawed, nor a discard date. During a surveyor interview with Certified Medication Technician, Staff F, on 3/4/2024 at 1:03 PM, she revealed that was unaware that the shakes needed to be dated when thawed. C. A surveyor observation on 3/4/2024 at 1:19 PM of the Bay kitchenette revealed the refrigerator contained 1 chocolate mighty shake and 12 vanilla mighty shakes without discard dates or dates when thawed. During a surveyor interview with Culinary Aide, Staff G, following the above observation she acknowledged the thawed mighty shakes did not have a discard date. D. A surveyor observation on 3/4/2024 at 1:21 PM of the Cove Unit Kitchenette revealed the freezer contained a box of cheese and pepperoni bagel bites which were not label or dated. During a surveyor interview following the above observation with Culinary Aide, Staff H, she revealed if there is no label on the food item it should be discarded. During a surveyor interview on 3/4/2024 at 2:27 PM with Staff I, she indicated the food and drinks in the kitchenettes need to be labeled and dated correctly, and if not, they need to be discarded. Additionally, she indicated the Mighty shakes should have been dated when brought to the unit and that the shakes would be good for 5 days. 2. Review of The Rhode Island Food Code 2018 Edition 4.601.11 reads in part, .(A) equipment food contact surfaces .shall be clean to sight . During the initial tour of the [NAME] House kitchenettes revealed the following findings: 1. [NAME] House #15 During a surveyor observation on 3/4/2024 at 10:46 AM, the ice machine an accumulation of a dark grey matter was noted along and on the sides of the condensation panel. During a surveyor interview following the above observation with Certified Nursing Assistant (CNA), Staff O, she acknowledged the above observations. Additionally, she revealed that an outside company last serviced to the ice machine on 12/4/2023. 2. [NAME] House #17 During a surveyor observation on 3/4/2024 at 9:07 AM, the ice machine the interior was noted to have black matter scattered on the inside of the door and on the top area. During a surveyor interview following the above observation with CNA, Staff P, she acknowledged the black matter inside the ice machine and could not provide evidence that it was kept clean. During a surveyor interview on 3/4/2024 at approximately 9:20 AM with Nurse Unit Manager, Staff N, she acknowledged the black matter and indicated that it should not be inside the ice machine; she stated it looked like mold. 3. [NAME] House #19 During a surveyor observation on 3/4/2024 at 11:25 AM, the ice machine was noted to have an accumulation of dark grey matter around the condensation panel. During a surveyor interview, immediately following the above observation with CNA, Staff Q, she acknowledged the dark grey matter accumulated around the condensation panel. 4. [NAME] House #21 During a surveyor observation on 3/4/2024 at approximately 12:00 PM, the ice machine had an accumulation of black matter that was scattered inside the door and on the upper area. During a surveyor interview following the above observation with Dietitian, Staff R, she acknowledged the ice machine was not clean and that the black matter appeared to be mildew.

Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to following a physician's order specific to as needed (PRN) medication for agitation for 1 of 6 residents reviewed, Resident ID #1. 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. Record review revealed Resident ID #1 was admitted to the facility in November of 2023, with diagnoses including, but not limited to, neurocognitive disorder with behaviors (behavioral and psychosocial symptoms of dementia that can include aggressive behavior), psychotic disturbance (mental disorder characterized by a disconnection from reality), and anxiety. Review of a care plan dated 12/8/2023, states in part, .resident has the potential to be physically aggressive towards elders. Interventions include, but are not limited to, administer medications as ordered . monitor/document for side effects and effectiveness .report PRN any signs or symptoms of resident posing danger to self and others. Review of physician orders dated 11/20/2023 and 12/13/2023 revealed Trazodone 50 mg [milligrams] to be administered PRN for agitation for 14 days. Record review of a progress note dated 12/7/2023 at 2:15 PM, states in part, .resident was walking into activity room when a fellow peer walked pass and resident struck fellow peer in the left shoulder and grabbed onto fellow peer's sweater. Additional review of a progress note written on the same date at 4:04 PM states in part, .resident exhibited increased agitation/anxiety this afternoon .resident observed pacing in dining room and hallway .expressing him/herself in an aggressive way and shaking hands with agitation . Review of a progress note at 11:15 PM on this date states in part, .resident combative with evening care hitting CNA. Additional review of progress notes revealed the following: -12/13/2023 at 11:48 AM, .resident combative with care .writer attempted to redirect with no effect and increased agitation noted with redirection .care ongoing, will continue to monitor. -12/13/2023 at 3:12 PM, .staff report resident was combative with care .increased agitation noted when staff encouraged resident to utilize walker .redirection and comfort provided with no effect. -12/13/2023 at 5:52 PM, .NP [Nurse Practioner] gave order to extent [SIC] PRN Trazodone once daily for agitation with additional 14 days. -12/18/2023 at 5:25 PM, authored by MD (Medical Doctor) which states in part, .neurocognitive disorder with behavioral disturbances .continue Trazodone 25 mg as needed. -12/26/2023 at 2:10 PM, .resident observed with increased agitation .verbal redirection provided with fair effect. -1/5/2024 at 2:46 PM, .elder was sitting in chair in the activity room with another elder sitting in front of [him/her] .no precipitating factors were noted prior to [name redacted] striking other elder .presents with increased agitation at this time. Record review failed to reveal evidence that the PRN Trazodone was administered to the resident for agitation as ordered following attempts at redirection with no effect. Additional record review revealed Resident ID #1 was involved in 2 separate resident-to-resident abuse incidents on 12/7/2023 and on 1/5/2024, both of which were unprovoked and involved him/her exhibiting physical aggression towards other residents. Review of the following incidents reported to the Rhode Island Department of Health by the facility states as follows: -12/7/2023, states in part, .as the elders passed each other in the hallway [name redacted] reached out and hit [name redacted] in the back/shoulder area and grabbed elder's sweater. Review of the facility's 5-Day Investigation report specific to facility system changes made to decrease the risk of similar incidents from occurring states in part, .[name redacted] resident seen by psych and med changes were made .will continue to be followed by psych. -1/5/2024, states in part, .[name redacted] resident was sitting in the activity room and [name redacted] resident was sitting in front of [him/her] .resident struck other resident in the back multiple times in an aggressive manner .incident appeared unprovoked. Review of the facility's 5-Day Investigation report specific to facility system changes made to decrease the risk of similar incidents from occurring states in part, .both elders suffer from dementia and are followed by psych services. During a surveyor interview on 1/22/2024 at approximately 2:27 PM with the Director of Nursing Services (DNS), she acknowledged that the resident exhibits agitation and anxiety and is followed by psych services. The DNS also acknowledged that the PRN order for Trazodone was not administered as indicated in the order for agitation. Additionally, the DNS revealed that she instructs staff to first try with redirection during a resident's bout of agitation, restlessness, and/or anxiety, however, when unsuccessful she indicated that her expectation is that staff would administer the PRN medication and document the effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 for 2 of 2 residents reviewed for skin conditions, Resident ID #'s 1 and 3. Additionally, for 1 of 1 residents reviewed with orders for a consultation with an outside specialist relative to the diagnosis of kidney failure, Resident ID #1. Findings are as follows: A. Record review of a community reported complaint submitted to the Rhode Island Department of Health on 11/30/2023 alleges Resident ID #1, was transferred from the nursing facility to an acute care hospital on [DATE]. Upon admission to the hospital, s/he was noted with a significant skin infection to his/her abdominal skin, groin, and a pressure ulcer to his/her buttocks. Additionally, the report states in part, .The [resident's family member] revealed that during the hospital admission, staff was assessing the rash and [the resident] stated that [s/he] felt as [s/he] has been 'shot down there.' . During a surveyor interview with the resident's family member on 12/1/2023 at 10:07 AM, revealed the following. The family member was informed by a hospital nurse that their loved one was, destroyed in the area of his/her chest, abdomen, groin, inner thighs, and sexual organ. The family member indicated the facility informed him/her of a quarter size fungal rash to [his/her] abdomen and that is all. [His/her sexual organ] looked like purple hamburger meat. The family member further indicated that a hospital physician told him/her that the resident was complaining of discomfort in the areas of his/her skin conditions and indicated that resident said s/he had been shot at the nursing home. Record review of a hospital document dated 10/3/2023 at 12:54 PM, titled, admission note, revealed the following in part, .Skin thin and fragile. Bottom with stage 1 [ a pressure ulcer characterized by non-blanchable redness] on L [left] buttock. Very excoriated [abraded skin damage] and reddened coccyx [tailbone], blanchable. Surrounding coccyx tissue purple, looks like old healing wound .patient noted to have significant excoriation to abdominal pannus [excess lower belly skin], as well as inner thighs and [sexual organ]. L inner thigh with significant fungal looking rash. [sexual organ] with excoriation and bleeding, patient very tearful upon cleaning . Record review of a facility policy titled, Pressure Injury, Wound and Skin Care Protocols, revised January 2019, revealed in part, .Provide a systemic approach and monitoring process for skin integrity and chronic wound care .To promote healing of chronic wounds in a .timely manner .On-going documentation by nurses in the medical record to describe the effectiveness of interventions and resident's response to therapy .The facility will address the resident's concerns and offer relevant alternatives, if the resident has refused specific treatments . Record review revealed Resident ID #1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, obesity, diabetes, kidney failure, and congestive heart failure. Record review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. Additionally, s/he required the physical assistance of one staff member for transferring, moving side to side while in bed, personal hygiene, and toilet use. Furthermore, s/he was documented as being incontinent of bowel and bladder and at risk for pressure ulcers or injuries. Record review of a care plan initiated on 8/31/2023 revealed a focus area indicating the potential or actual impaired skin integrity of the buttocks. Interventions included, but are not limited to, .follow facility protocols for treatment or injury .Weekly treatment documentation to include measurements of each area of skin breakdown's width, length, depth, type of tissue and exudate [drainage] and any other notable changes or observations . Record review of the facility admission skin integrity document completed 8/24/2023, revealed the following in part, .Wide range of excoriation to the bilateral buttocks .Scab on left heel; boggy-blanchable [abnormal texture of skin characterized by sponginess; red when it blanches, turns white when pressed with a fingertip, and then immediately turns red again when pressure is removed] . Additional record review revealed of a progress note dated 8/24/2023 at 10:58 PM, which states in part, .excoriated lesion on peri anal area . Record review revealed the following physician's orders: - 8/25/2023, Clean with normal saline and apply Triad [protective cream used for open wounds] to buttocks every day and evening shift for excoriated area until resolved - 8/25/2023, Apply skin prep & off-loaded heels in bed. every shift for Blanchable redness to the left heel (boggy) . - 9/11/2023, Weekly skin evaluation by nurse. PLEASE DOCUMENT IN PROGRESS NOTES UNDER 'SKIN EVALUATION .' every day shift every Mon [Monday] for Weekly Skin Check . Record review failed to reveal an order for the excoriated areas to his/her peri area. Further record review revealed the following entries for the weekly skin evaluations: - 8/28/2023 12:09 AM, .Known excoriated area to buttocks .Discomfort to buttocks improving according to resident . This skin evaluation failed to reveal evidence of an assessment of his/her left heel or the excoriated peri/anal region. - 9/3/2023 4:48 PM, .Known redness to sacral coccygeal [lower spine] area. small scabbed area to left heel . This evaluation failed to reveal evidence of an assessment of the peri/anal region. - 9/11/2023 11:26 AM, .Weekly skin check, PT [patient] continues with redness to buttocks . This skin evaluation failed to reveal evidence of an assessment of his/her left heel or the excoriated peri/anal region. - 9/18/2023 11:42 AM, .No new skin issues noted . This skin evaluation fails to reveal evidence of an assessment of his/her left heel or the excoriated peri/anal region. - 9/25/2023 10:19 AM, .weekly skin check, PT [patient] continues with red bottom . skin evaluation fails to reveal evidence of an assessment of his/her left heel or the excoriated peri/anal region. Additional record review revealed the 10/2/2023 skin evaluation was documented as not administered and indicated to see the nurses progress note. Furthermore, the skin evaluation note dated 10/2/2023 at 3:48 PM, failed to reveal evidence of documentation of the weekly skin evaluation per the order. Record review failed to reveal evidence of measurements of the left heel scab after 8/24/2023 or evidence that this wound was healed. Additionally, the record failed to reveal evidence that the resident's left heel scab was assessed weekly or evidence of the effectiveness of the interventions and the resident's response to the treatment per the facility policy. Record review revealed a progress note dated 9/29/2023 at 11:24 PM, indicating the assigned Nursing Assistant (NA) found an odorous rash to the resident's left abdomen skin fold. The note states in part, .noted wide range of skin rash to the area .received order for Nystatin [prescription antifungal medication] powder bid [twice a day] for 14 days by on call [physician-name redacted] . Further record review revealed the resident was transferred to an acute care hospital on the evening of 10/2/2023. Additionally, the facility transfer form that was sent to the hospital with the resident, dated 10/2/2023 at 6:38 PM under SECTION D. 2. Skin/Wound Care, failed to reveal evidence of documentation relative to the resident's skin conditions or treatments. A surveyor telephone interview with the Registered Nurse, Staff A, who authored the admission skin integrity document, and progress notes dated 8/24 and 9/29/2023, was attempted and unsuccessful on 12/1/2023 at 3:11 PM and 12/4/2023 at 9:04 AM. During a surveyor interview on 12/1/2023 at 3:22 PM, with Registered Nurse, Staff B, she acknowledged that she was the resident's assigned nurse on 10/2/2023 during the 7:00 AM - 3:00 PM shift and revealed that the resident was not transferred to the hospital on her shift but at some time during the 3:00 PM - 11:00 PM shift. Additionally, she was unable to provide evidence that she completed the resident's weekly skin evaluation on 10/2/2023 and indicated she could not recall the condition of the resident's skin. B. Record review of a nursing progress note dated 9/20/2023 at 3:54 PM, revealed that the physician gave orders for the resident to have a consultation with his/her nephrologist [physician who specializes in conditions of the kidneys]. Further record review failed to reveal evidence that an appointment was scheduled. During a surveyor observation and interview on 12/4/2023 at 8:52 AM, with the scheduler, Staff C, she revealed that she schedules medical appointments for the residents. She was unable to provide evidence that a nephrology appointment was scheduled or attempted to be scheduled for Resident ID #1. During a surveyor interview on 12/4/2023 at 11:20 AM, with the Director of Nursing Services (DNS), she was unable to provide evidence that that an appointment was scheduled or attempted to be scheduled with the nephrologist per the physician's order on 9/20/2023. During a surveyor interview on 12/5/2023 at 10:09 AM, with the resident's physician, she acknowledged that she gave an order on 9/20/2023 for the resident to be seen by his/her nephrologist and cardiologist. Additionally, she indicated that despite it being difficult to schedule outside appointments for nursing home residents, she would expect there to be evidence in the resident's medical record that an attempt was made to schedule an appointment with the nephrologist per the physician's order. C. Record review revealed Resident ID #3 was admitted to the facility October 2019, with diagnoses including, but not limited to, Alzheimer's disease and stroke. Record review of a MDS assessment dated [DATE] revealed s/he has one unhealed stage 2 pressure ulcer (a wound caused by pressure that may appear like a cut or blister). Record review revealed the following physician's orders: - 10/26/2023, Cleanse L [left] heel with NS [normal saline], apply medi-honey [medical honey, a gel used to treat wounds] f/b [followed by] allevyn [dressing] every other day until strongly healed .for wound care . Record review of the documents titled, SPECIALTY PHYSICIAN WOUND EVALUATION & MANAGEMENT SUMMARY, revealed the following entries: - 11/16/2023, The document revealed the resident was seen for an assessment of his/her left heel stage 2 wound. The note states in part, .FOLLOW-UP Evaluation by wound care specialist within 7 Day (s) with further intervention as indicated . - 11/22/2023, .The patient's visit has been rescheduled . - 11/30/2023, .The patient's visit has been rescheduled . Record review of a nursing progress note dated 11/22/2023 at 10:58 AM, revealed the resident's left heel wound was assessed. The note indicates the wound measurements were documented and that the wound specialist will follow him/her every other week. Additional record review failed to reveal evidence that wound measurements were documented after 11/22/2023 or evidence of documentation of the left heel wound which would include a description of the wound bed, any drainage, and measurements after 11/22/2023. Further record review of a skin evaluation progress note dated 11/30/2023 at 9:54 PM, failed to reveal evidence of documentation of the left heel stage 2 pressure ulcer. During a surveyor interview on 12/4/2023 at 11:13 AM, with Licensed Practical Nurse, Staff D, she revealed that Resident ID #3 had a wound to his/her left heel with an active treatment order in place. During a surveyor interview on 12/4/2023 at 1:22 PM with the DNS and the Administrator, they were unable to provide evidence that Resident ID #'s 1 and 3 received treatment and care in accordance with professional standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure a physician reviewed the resident's total program of care, including medications and treatments, at each visit, for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: Record review revealed Resident ID #1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, kidney failure, insomnia, depressive disorder and anxiety. Record review revealed s/he was admitted to the facility with impaired skin to his/her buttocks and a scab to the left heel. Record review revealed the following physician's orders with a start date 8/25/2023: - Apply skin prep and off-load heels in bed. Every shift for Blanchable redness to the left heel (boggy) - Clean with normal saline and apply Triad to buttocks every day and evening shift for excoriated area until resolved. Further record review revealed a progress note dated 9/29/2023 at 11:24 PM, indicating the assigned Nursing Assistant (NA) found an odorous rash to the resident's left abdomen skin fold. The note states in part, .noted wide range of skin rash to the area .received order for Nystatin [prescription antifungal medication] powder bid [twice a day] for 14 days by on call [physician-name redacted] . Record review revealed the following physician's orders were in place without a stop date: - 8/24/2023, Trazodone 50 milligrams (MG) tablet, give one tablet by mouth as needed for insomnia at bedtime. - 9/27/2023, Trazodone 25 MG by mouth as needed for anxiety, give prior to therapy. Further record review of the physician's progress notes for Resident ID #1 failed to reveal evidence of a review of the resident's total program of care at the time of the required visits which included Trazodone PRN ordered without a stop date (Refer to F758) or treatments relative to his/her skin condition (Refer to F684). During a surveyor telephone interview on 12/4/2023 at 4:20 PM, with the resident's physician she indicated that she was not aware of the resident's skin condition and indicated she would have expected staff to make her aware. Additionally, she acknowledged she did not document a review of the resident's total program of care at the required visits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary psychotropic drugs for 1 of 1 resident reviewed with an order for psychotropic medication ordered as needed (PRN) without a stop date, Resident ID #1. Findings are as follows: According to the State Operation Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023 states in part, .PRN orders for psychotropic drugs are limited to 14 days. Except .if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order . Record review revealed Resident ID #1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, kidney failure and insomnia. Record review revealed an unsigned pharmacy recommendation document dated 9/20/2023 which states in part, .REPEATED RECOMMENDATION from 8/25/2023 .[Resident ID #1] has a PRN order for a sedative/hypnotic, without a stop date: Trazodone for insomnia .This order has been in place for more than 14 days which exceeds the maximum allowed per federal regulations . Record review revealed the following physician's orders without a stop date: - 8/24/2023, Trazodone 50 milligrams (MG) tablet, give one tablet by mouth as needed for insomnia at bedtime. - 9/27/2023, Trazodone 25 MG by mouth as needed for anxiety, give prior to therapy. Record review of the September and October 2023 Medication Administration Records (MAR) revealed the Trazadone was administered on the following dates, which was 19 doses after the medication was in place for greater than 14 days: - 9/8, 9/9, 9/10, 9/11, 9/12, 9/13, 9/14, 9/15, 9/16, 9/17, 9/19, 9/20, 9/22, 9/23, 9/28, 9/27, 9/28, 9/29 - 10/1 Further record review failed to reveal evidence of documentation from the physician indicating that the PRN Trazodone order should be extended beyond 14 days, or a rationale indicating the duration. During a surveyor interview on 12/4/2023 at 11:47 AM, with the Director of Nursing Services, she acknowledged the Trazodone PRN order was in place for Resident ID #1 since admission, without a stop date and indicated it should have had a stop date. Additionally, she was unable to provide evidence of documentation from the physician indicating the order should be extended or a rationale indicating the duration. During a surveyor interview on 12/4/2023 at 4:20 PM, with the physician, she indicated that she reviews PRN psychotropic medications on the 14-day mark with the nurse and extends the order if the resident needs it. Additionally, she indicated that she would give an order to extend the medication for another 14 days and then review and document in the resident's record. Furthermore, she acknowledged that Resident ID #1's record lacked documentation from her indicating that the medication should be extended beyond 14 days or a rationale indicating the duration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure residents are free from neglect for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of a facility reported incident received by the Rhode Island Department of Health on 7/10/2023 states in part, During set up of the dining room for dinner [Resident ID #1] sat in a chair and grabbed a glass of soda .CMT [Certified Medication Technician], told elder to please put soda down that it was another elder's soda. [resident] poured the soda on the floor and dropped the glass. CMT attempted to assist elder out of DR [dining room] due to broken glass, elder sustained a skin tear to [his/her] (?). Per witness, CMT stated [S/he] is a [f*ck*ng b*tch] I can't stand [him/her]. Full investigation to follow. Record review revealed Resident ID #1 was admitted to the facility in May of 2023 with diagnosis including, but not limited to, unspecified dementia and glaucoma. Record review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 6 out of 15 indicating the resident has severely impaired cognition. Additionally, s/he requires supervision with transfers,walking in his/her room and the corridor. Record review of an undated statement authored by Nursing Assistant, Staff D, indicated that she witnessed the above incident and states in part .Around 4:30 PM on 7/10/2023 I walked into the dining room on the [facility unit] to start setting up trays. When I walked in I saw [Resident ID #1] reaching for a glass .of soda that [Staff E] had just set on the other side of the table for the people that were supposed to be sitting at that specific table, when he saw [Resident ID #1] he started to raise his voice telling [him/her] 'that's not yours' .When [s/he] still continued to grab the cup he walked up to [him/her] and began trying to take it from [his/her] hand. Within the struggle the glass got tipped over, spilled, and fell on the table/floor and smashed. Once this happened [Staff E] grabbed [Resident ID #1] by [his/her] arm ripping [him/her] from the chair raising his voice telling [him/her] 'No you need to get up now'.[S/he] screamed that he was hurting [his/her] arm, while [s/he] was resisting standing up. This is when I jumped in and said, 'there is broken glass its ok come with me' and I grabbed the back of [his/her] pants so [s/he] didn't fall leading [Resident ID #1] out of the dining room, [Staff E] stated loud enough for us to hear '[s/he] is a [f*ck*ng b*tch] I can't stand [him/her] .' at this time I also noticed a medium skin tear on left forearm that was where [Staff E] was just grabbing [his/her] arm .As myself and [Staff F] were taking care of the wound [Staff E] walked by and said 'huh [s/he] has a skin tear?' I said 'yes [s/he] does' and he walked back into the dining room. Record review of an undated statement authored by CMT, Staff E, states in part, During the setup of the dining rm. I poured the drinks and placed them on the tables. [Resident ID #1] was sitting in one of the chairs at the table next to the 3 window areas. As I placed the drink down [s/he] grabbed .the glasses and I asked [him/her] to put it down because that wasn't [his/her] glass-[s/he] poured it out then dropped it on the floor. At that pt [point] I had told [him/her] [s/he] had to leave and I got [him/her] out of the chair. [Staff C] helped me get [him/her] to leave the area and I cleaned up the breakage. Further review of the above-mentioned statement by Staff E revealed an addendum that indicates Resident ID #1 sustained a skin tear to his/her left wrist during the above incident. During a surveyor interview with Resident ID #1 on 7/13/2023 at approximately 2:30 PM, s/he was unable to recall how s/he obtained the skin tear to his/her wrist. During a surveyor telephone interview on 7/14/2023 at 9:18 AM with Registered Nurse, Staff G, she revealed that she did not witness the incident at the time as she was in the nursing office. Additionally, she revealed that she reported the incident to the resident's family member indicating that Resident ID #1 sustained a skin tear when Staff E had got him/her out of the chair and grabbed his/her wrist. During a surveyor interview on 7/14/2023 at 11:43 AM with Staff E, he revealed that he was not aware that the resident sustained a skin tear at the time of transferring [him/her] out of the chair. He further revealed that at the time of the transfer, [S/he] didn't say anything [s/he] got kind of scared. [S/he] yelled a little bit with transfer. Record review reveals a physician's order dated 7/10/2023 states in part, Please change right[sic] dorsal wrist dressing every PM. Cleanse with NS [salt and water solution] apply xeroform [petroleum dressing] and allevyn [dressing] . Record review of a progress notes dated 7/10/2023 revealed the following: -7:00 PM (skin evaluation) New skin tear obtained tonight to Left dorsal wrist. Staff was assisting the patient out of the chair in the dining room obtained skin tear from contact with hand. -7:50 PM Patient assisted out of the chair in the dining room tonight. Patient obtained a skin tear to [his/her] Dorsal left wrist. Dressing applied, family and MD notified. During a surveyor interview with the Director of Nursing, on 7/14/2023 at approximately 12:50 PM, she was unable to provide evidence that the resident was kept free from abuse. As a result of this incident the facility provided Staff E with training on abuse, neglect, mistreatment and resident rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that a resident with an injury of unknown origin was thoroughly investigated for 1 of 3 residents reviewed, Resident ID #3. Findings are as follows: Record review of a community reported complaint sent to the Rhode Island Department of Health on 7/12/2023 indicates that Resident ID #3 has bruising on his/her body in multiple places. Record review revealed the resident was admitted to the facility in September of 2021 with diagnoses including, but not limited to, Alzheimer's disease with late onset, dementia, and anxiety. Record review of the resident's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed s/he has severe cognitive impairment. During a surveyor observation of the resident on 7/13/2023 at approximately 2:00 PM, in the presence of Nursing Assistant (NA), Staff A, revealed s/he was observed with bruising to the left upper arm, left elbow, right hand, wrist and thigh. Record review of resident's progress notes revealed the following: - 7/7/2023 at 9:00 AM- Bruise noted on top of left upper arm, has scratch alongside. Faded lite yellow bruise on forehead. Small bruise and skin tear on top of right hand. Unknown origin. Daughter aware. - 7/10/2023 at 1:31 PM- Resident noted with several bruises to bilateral upper extremities. 2 scratches to L [left] upper arm . - 7/11/2023 at 2:47 PM- previously reported bruising Further record review failed to reveal evidence of an investigation on the injuries of unknown origin occurred as documented in the 7/7/2023 and 7/10/2023 progress notes. During a surveyor interview on 7/14/2023 at approximately 12:40 PM with the Director of Nursing Services, she was unable to provide evidence that an investigation was conducted for the injuries of unknown origin documented in the resident's progress notes on 7/7 and 7/10/2023 until the surveyor brought it to the facility's attention.

Based on surveyor observation, record review, and staff interview, it has been determined the facility failed to provide care in accordance with a resident's plan of care for 1 of 2 residents relative to behavior monitoring, Resident ID #399. Findings are as follows: Record review revealed the resident was admitted to the facility in December of 2022 with diagnoses including, but not limited to, Alzheimer's disease, anxiety disorder, and major depressive disorder. Record review of a care plan dated 1/3/2023 revealed in part, .resident uses psychotropic medications [medications that can alter thoughts, mood, emotions, and/or behavior] r/t [related to] Behavior management .Monitor for side effects and effectiveness Q-SHIFT [every shift] . Review of the record failed to reveal evidence that staff was monitoring for side effects and effectiveness of the psychotropic medications every shift as indicated per the care plan. During surveyor observations on the following dates and times, revealed the resident lying in his/her bed yelling out: - 1/18/2023 at 11:16 AM - 1/18/2023 at 12:05 PM - 1/19/2023 at 12:53 PM During a surveyor interview immediately following the third observation above with Nursing Assistant, Staff A, she revealed the resident screams and yells out often. During a surveyor interview with the Director of Nursing Services on 1/23/2023 at 12:46 PM, she revealed the resident should have target behavior monitoring documented every shift if on psychotropic medications. She was unable to provide evidence that the care plan for psychotropic medications was followed.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to following a physician's plan of care for 1 of 3 residents reviewed for wound care, Resident ID #136. Findings are as follows: Review of a facility policy titled, Dressing Change - Clean Technique states in part, Policy: The dressing change performed by a licensed nurse following a Physician or Registered Nurse Practitioner Order is done to provide an appropriate safe environment conducive to wound healing . Record review revealed the resident was admitted to the facility in October of 2022 with diagnoses including, but not limited to, fracture of the right hip and mild cognitive impairment. Review of a Wound Evaluation dated 1/18/2023 revealed the resident has a deep tissue injury (intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister) caused by pressure to his/her right heel. Review of the physician's orders revealed the following wound care treatment: Cleanse right heel with vashe [wound cleanser] and apply mepitel [contact layer designed to minimize pain] sheet f/b [followed by] allevyn [foam dressing] heel cup daily and PRN [as needed] everyday shift for Wound Healing. During a surveyor observation on 1/19/2023 at 7:53 AM, with Registered Nurse, Staff B, revealed the resident has an open wound to his/her right heel. Staff B was then observed cleaning the resident's right heel with normal saline and applying a 4X4 Allevyn dressing. During the wound care the resident was yelling out in pain. During a surveyor interview directly following the above observation with Staff B, she acknowledged that she did not follow the physicians order for wound care, and she failed to apply the mepitel sheet to minimize pain. During a surveyor interview on 1/19/2023 at 9:30 AM with the Director of Nursing Services in the presence of the Staff Educator, she indicated that Staff B did not follow the physician's order for wound care. She further revealed she would expect the nurse follow to the physician's orders.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents that are fed through a feeding tube receive the appropriate treatment and services to prevent complications for 1 of 1 residents reviewed with a feeding tube, Resident ID #360. Findings are as follows: Review of the facility policy titled, Medication Administration via Gastrostomy [ G-Tube; a tube surgically placed as an opening through the abdominal wall and into the stomach for feeding and drainage] Tube, revised 1/2/2022 states in part, PROCEDURE .2. Check for correct placement of the gastrostomy tube by making a visual inspection along with withdrawing gastric contents as follows .Aspirate gastric secretions .3. If placement is not completely assured, do NOT administer the medication. Record review revealed the resident was admitted to the facility in January of 2023 with diagnoses including, but not limited to, dysphagia (difficulty swallowing) following nontraumatic intracerebral hemorrhage (bleeding into the brain tissue), gastrostomy status and Parkinson's disease (progressive disorder that effects the nervous system). Record review revealed the following physician's orders: - Bromocriptine Mesylate Oral Capsule 5 MG (Bromocriptine Mesylate) Give 2 capsule via G-Tube three times a day for Parkinson's - Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa) Give 2 tablet via G-Tube three times a day for Parkinson's - Midodrine HCl Oral Tablet 5 MG (Midodrine HCl) Give 1 tablet via G-Tube one time a day for monitoring [medication for blood pressure] During a surveyor observation on 1/20/2023 at 11:33 AM, Registered Nurse, Staff D, failed to check placement of the resident's gastrostomy tube by aspirating gastric secretions prior to administering the above medications. During a surveyor interview on 1/20/2023 at 11:43 AM with Staff D, he acknowledged that he failed to check the placement of the gastrostomy tube by withdrawing gastric contents per facility policy. During a surveyor interview on 1/23/2023 at 11:38 AM with the Director of Nursing Services, she revealed that she would expect the nurse to check for correct placement of the gastrostomy tube prior to administering medications per facility policy.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that each resident's medication regimen is free of medication error rates of 5% or greater. Based on 26 opportunities for error, there were 4 errors involving Resident ID #360, resulting in an error rate of 15.38%. Findings are as follows: Record review of a facility policy titled, Medication Administration via Gastrostomy Tube [a tube surgically placed as an opening through the abdomen wall and into the stomach for feeding and drainage] revised 1/2/2020, states in part, .4. Each medication is to be prepared separately .7. Each medication is to be instilled into the tube separately. Flush the tube with 15 cc [cubic centimeters] of sterile (preferred) water between each medication . Per State Operations Manual, Appendix PP, Guidance to Surveyors for Long Term Care Facilities states in part .Observe whether the crushed medications are combined for administration via feeding tube and flushed between each medication. If so, the number of errors would equal the number of medications that were combined . Record review revealed the resident was admitted to the facility in January of 2023 with diagnoses including, but not limited to, Parkinson's disease (a progressive disorder that affects the nervous system), hypotension (low blood pressure), and gastrostomy status. Record review revealed the following physician orders: -Bromocriptine Mesylate (medication used to treat Parkinson's disease) oral capsule 5 milligrams (mg), give 2 capsules via gastrostomy tube three times a day, with a start date of 1/16/2023 -Carbidopa-Levodopa (medication used to treat Parkinson's disease) oral tablet 25-100 mg, give 2 tablets via gastrostomy tube three times a day, with a start date of 1/16/2023 -Midodrine hydrochloride (medication used to treat low blood pressure) oral tablet 5 mg, give 1 tablet via gastrostomy tube once a day, with a start date of 1/17/2023. During a surveyor observation of the Medication Administration task on 1/20/2023 at 11:19 AM, Registered Nurse, Staff D, prepared to administer the following medications: -2 Bromocriptine 2.5 mg tablets -2 Carbidopa-Levodopa 25-100 mg tablets -1 Midodrine hydrochloride 5 mg tablet. During a surveyor interview on 1/20/2022 at 11:23 AM with Staff D, he indicated to the surveyor he was ready to administer the medications to the resident. The surveyor then questioned Staff D and at that time he acknowledged that he prepared a total of 5 mg of Bromocriptine rather than the 10 mg as ordered. During a surveyor observation of the Medication Administration task immediately following the above interview, Staff D, crushed together the three above-listed medications. Staff D instilled 40 milliliters (mL) of sterile water and then instilled all the crushed medications mixed with 60 mL of sterile water into the gastrostomy tube. Staff D failed to immediately secure the gastrostomy tube, allowing for the medication to spill out onto the resident's pants. During a surveyor interview on 1/20/2023 at 11:43 AM with Staff D, he acknowledged he crushed the three above-listed medications and administered them together through the gastrostomy tube. During a surveyor interview on 1/23/2023 at 11:38 AM with the Director of Nursing Services, she revealed she would expect staff to administer medications as ordered by the physician. She further revealed that she would expect medications to be crushed and administered separately as outlined by the facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from significant medication errors for 1 of 1 resident reviewed without an order for anticoagulation therapy, Resident ID #141. Findings are as follows: Record review revealed the resident was readmitted to the facility in December of 2022 with diagnoses including, but not limited to, chronic obstructive pulmonary disorder and type II diabetes mellitus. Review of a Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 13 out of 15, indicating s/he is cognitively intact. Review of a progress note dated 1/13/2023 at 10:10 AM, states in part, Resident received Heparin [a medication used to decrease the clotting ability of blood] 5000 Units that was not ordered for [him/her] . During a surveyor interview on 1/20/2023 at 8:20 AM with Registered Nurse, Staff D, he revealed that he was the nurse that made the medication error and he failed to identify the correct resident prior to the administration. During a surveyor interview on 1/23/2022 at 10:04 AM with the resident s/he acknowledged that s/he received the wrong medication on 1/13/2023. During a surveyor interview on 1/20/2022 at 11:47 AM, with the Director of Nursing Services she acknowledged that the resident received 5000 units of Heparin that was not ordered for him/her.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to follow standard precautions to prevent the spread of infection for 1 of 3 residents observed for wound care, Resident ID #136, and 1 of 7 residents reviewed for medication administration, Resident ID #360. Findings are as follows: 1. Review of a policy titled, Dressing Change - Clean Technique states in part, .Procedure .3. Wash hands and put on gloves. 4. Remove soiled dressing and discard into plastic bag. Change gloves. Clean wound with sterile normal saline solution or as specified by Physician. 5. Remove gloves and apply dressing as specified by Physician, touching only the outer part of dressing . Record review revealed Resident ID #136 was admitted to the facility in October of 2022 with diagnoses including, but not limited to, fracture of the right hip and mild cognitive impairment. During a surveyor observation of wound care on 1/19/2023 at 7:53 AM, with Registered Nurse (RN), Staff B, she was observed entering the residents room wearing gloves and carrying wound supplies in her hand. She was then observed lifting the resident's right foot off of the bed, cleaning the wound with gauze and normal saline and then applying a new clean dressing. During the observation, the nurse failed to perform hand hygiene or apply clean gloves prior to touching the wound, after cleaning the wound or when applying a clean dressing. During a surveyor interview immediately following the above observation with Staff B, she acknowledged she failed to perform hand hygiene or change her gloves at any time during the dressing change. During a surveyor interview on 1/19/2023 at 9:30 AM with the Director of Nursing Services (DNS) in the presence of the Staff Educator, she revealed that she would expect the nurse to perform hand hygiene and change her gloves between cleaning the wound and applying a clean dressing per the facility policy. 2. Review of a facility competency titled, Nurse/Medication Technician Evaluation Checklist states in part, .3. Washes/Sanitizes hand .6. Pours without touching medication . Record review revealed Resident ID #360 was admitted to the facility in January of 2023 with a diagnosis including, but not limited to, gastrostomy status (a tube surgically placed as an opening through the abdomen wall and into the stomach for feeding and drainage). During a surveyor observation on 1/20/2023 at 11:19 AM, of RN, Staff D, he failed to perform hand hygiene prior to preparing and touching the resident's medications with his bare hands. Additionally, Staff D failed to perform hand hygiene or apply gloves prior to initially accessing the resident's gastrostomy tube to administer the medication. During a surveyor interview on 1/23/2023 at 11:38 AM with the DNS she revealed that she would expect staff to perform hand hygiene and apply gloves prior to touching resident medication and accessing a gastrostomy tube.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 8 residents reviewed for pressure ulcers, Resident ID #65. Findings are as follows: Record review revealed the resident was admitted to the facility in December of 2021 with a diagnosis including, but not limited to, Alzheimer's disease. Review of the Minimum Data Set assessment dated [DATE] revealed the resident has two unstageable (inability to view the base of the wound to accurately determine wound stage) pressure ulcers, (one on the resident's left heel and another on the right, lateral [side] of foot). Review of a care plan dated 6/30/2022 revealed in part, Pressure Ulcers: I am at risk for pressure ulcers as I need assist with mobility. I have a unstageable [pressure ulcer] on my left heel and unstageable wound on my right lateral foot .Offload heels while in bed. Further review of the care plan revealed a focus area revised on 12/14/2022 for Wound Management: Wounds to bilateral feet, with interventions including Evaluate ulcer characteristics .Measure ulcer .at regular intervals .Monitor ulcer for signs of infection .Monitor ulcer for signs of progression or declination .Notify provider if no signs of improvement on current wound regimen . Record review revealed the following physician's orders relative to pressure ulcer management: -Offload heels while in bed every shift for wound care - .Cleanse open area to left heel .apply wound vac [medical device that provides vacuum-assisted closure to help wounds heal] to wound continuously . -Ensure wound vac is running .continuously every shift -Clean right lateral foot with normal saline, apply santyl [wound treatment ointment] to wound bed . Record review of a progress note dated 8/7/2022 at 7:42 PM states in part, Residents left heel, has a dark area . Review of a wound evaluation dated 8/10/2022 revealed a newly, in house acquired deep tissue injury to the left heel measuring 3.38 cm (centimeters) x 3 cm. Further record review revealed a treatment plan that included heel suspension and to cleanse the wound with normal saline. No dressing was required at that time. Review of a progress note dated 11/2/2022 revealed the wounds on both feet had an increase of seropurulent [drainage that may be indicative of an infection] drainage and an odor present with the doctor's recommendation to refer the resident to a wound clinic. Review of a Wound Care Center document dated 12/5/2022 revealed in part, .Wound #1 Left Calcaneus [left heel] Wound Vac to wound continuously .offload areas as much as possible .Wound #2 Right, Lateral Foot .offload areas . Further record review failed to reveal evidence of weekly pressure ulcer documentation for the left or right pressure ulcer, noting several weeks of missed assessments including, but not limited to, measurements, exudate (drainage), description and characteristics of wound bed, edges, and surrounding tissue between 11/30/2022 and 1/13/2023. Review of the left heel pressure ulcer evaluations revealed the following: -11/30/2022: 2.41 cm x 2.33 cm -1/13/2022: 2.51 cm x 2.84 cm During surveyor observations on the following dates and times revealed the resident was lying in bed with his/her heels directly on the mattress: -1/18/2023 at 10:29 AM -1/19/2023 at 8:54 AM -1/19/2023 at 10:26 AM -1/20/2023 at 8:10 AM During a surveyor interview at 1/19/2023 at 10:26 AM with Nursing Assistant, Staff C, she acknowledged the resident's heels were not off-loaded at that time and were in direct contact with the mattress. During a surveyor interview on 1/20/2023 at 8:54 AM with the Director of Nursing Services, she was unable to provide evidence of weekly pressure ulcer assessments. Additionally, she would expect the resident's heels to be offloaded while in bed and routine wound assessments to be completed per the plan of care.

Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure that food is served in accordance with professional standards for food service safety, relative to 4 of 4 Greenhouse units, #15, #17, #19, and #21. Findings are as follows: 1. During surveyor observations of Greenhouse unit #21 on 1/19/2023 at 8:35 AM and on 1/20/2023 at 1:11 PM revealed the following items in the freezer: - A freezer locked bag of 5 biscuits dated 11/7/2022-2/7/2023 with visible freezer burn. - A freezer locked bag of 14 biscuits dated 12/5/2022-3/5/2023 with visible freezer burn. - A freezer locked bag of chicken thighs dated 10/31/2022-1/31/2023 with visible freezer burn. - A container of clam soup dated 12/21/2022-2/21/2023 with visible freezer burn. During a surveyor interview with the Food Service Director (FSD) following the above observations on 1/20/2023 at 1:11 PM, he acknowledged the above items had freezer burn and should be discarded. 2. The Rhode Island Food Code 2018 Edition 3-501.19 Time as a Public Health Control reveals in part; .the food shall have an initial temperature of 5 degrees Celsius (41 degrees Fahrenheit) or less when removed from cold holding temperature control . A surveyor observation of the breakfast meal on 1/19/2023 at 8:40 AM in Greenhouse #21 revealed a 64 oz carton of half and half sitting on the counter, not on ice, until 9:04 AM. At 9:04 AM Shahbaz (staff that provide personal care) Staff E, put the half and half in the refrigerator. During a surveyor interview immediately following the above observation, the surveyor asked Staff E to take out the half and half and obtain the temperature. The half and half had a temperature reading of 55 degrees Fahrenheit (F). Staff E acknowledged that the half and half was sitting out too long and was not kept at 41 degrees F or below and should be discarded. 3. The Rhode Island Food Code 2018 Edition 2-402.11 revealed in part, .food employees shall wear hair restraints, beard restraints that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment During a surveyor observation on 1/19/2023 at approximately 8:40 AM in Greenhouse #21, Staff F was observed preparing breakfast without wearing a hair restraint. During a surveyor interview with Staff E following the above observation she revealed hair restraints are not worn when preparing meals. A surveyor observation on 1/20/2023 at 8:37 AM in Greenhouse unit #19 revealed Shahbaz, Staff G preparing eggs without wearing a hair restraint. During a surveyor interview with Staff G immediately following the above observation she revealed Shahbaz staff do not wear hair restraints. A surveyor observation on 1/20/2023 at 9:42 AM in Greenhouse unit #17 revealed Shahbaz Staff H preparing eggs without wearing a hair restraint. During a surveyor interview with the FSD on 1/20/2023 at 1:11 PM, he acknowledged the Shahbaz staff in Greenhouse units #17, #19, and #21 should all be wearing hair restraints while preparing food. A surveyor observation on 1/23/2023 at 12:01 PM in Greenhouse unit #15 revealed Staff I preparing lunch without wearing a hair restraint. During a surveyor interview with Staff I immediately following the above observation, she revealed hair restraints do not need to be worn when preparing food. During a surveyor interview with the FSD on 1/23/2023 at 12:52 PM, he acknowledged that when preparing food, hair restraints should be worn.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interview, it has been determined that the facility failed to ensure a resident's right to refuse, and/or discontinue treatment was maintained for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of a facility reported incident received by the Rhode Island Department of Health on 11/28/2022, indicated that a Nursing Assistant (NA) was rough with Resident ID #1 during care. Review of the resident's record revealed s/he was admitted to the facility in February of 2019 with diagnoses including, but are not limited to; dislocation of left shoulder joint, subluxation (partial dislocation) of right shoulder joint, spinal stenosis (can put pressure on the spinal cord and the nerves within the spine) and Polyosteoarthritis (results in pain and swelling of the joints). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 12, indicating that the resident has moderate cognitive impairment. Further review of the MDS revealed the resident has upper extremity impairments to both sides and a lower extremity impairment to one side. Additionally, the MDS revealed the resident is an extensive assist of 2 staff members for bed mobility. Additional record review revealed a care plan dated 2/8/2019 revealing the resident has a history of pain in both rotator cuffs and chronic pain to both knees due to arthritis. Interventions include, but are not limited to; observe and report changes if resident is resistive to care. During a surveyor interview with the resident on 11/28/2022 at 2:51 PM s/he revealed that on the morning of 11/26/2022, both NAs Staff A and B, were rough and loud with him/her when s/he was brought back to bed and being repositioned. S/he revealed that the NAs were not listening to him/her on how s/he likes to get into bed and indicated that s/he was very upset about it. S/he further indicated that the NAs were rolling him/her from side to side and s/he asked them to stop and they did not listen to him/her. During a surveyor interview with NA, Staff C, on 11/28/2022 at 4:11 PM, she revealed that the resident does not like to be boosted in bed and that the resident has a particular way s/he likes to be positioned when s/he is getting into bed to avoid being boosted. During a surveyor interview with Staff B, on 11/28/2022 at 4:55 PM, she revealed that Staff A had asked her for help with boosting the resident in bed. She further revealed that the resident was refusing to get boosted in bed making statements such as, no, leave me like this, but they continued boosting the resident anyway. During a surveyor interview with the Director of Nursing Services on 11/28/2022 at 6:10 PM, she was unable to provide evidence that the facility ensured Resident ID #1's right to refuse, and/or discontinue treatment was maintained.