What is Orchard View Manor's CMS rating?

Orchard View Manor has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Does Orchard View Manor have any serious inspection findings?

Yes, Orchard View Manor has 7 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 64 total deficiencies from recent inspections.

What are the staffing levels at Orchard View Manor?

Orchard View Manor has a four-star staffing rating from CMS with 0.74 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is Orchard View Manor located?

Orchard View Manor is located in East Providence, RI. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does Orchard View Manor have?

Orchard View Manor has 166 certified beds.

Who owns Orchard View Manor?

Orchard View Manor is a for profit - corporation facility and is part of the ATHENA HEALTHCARE SYSTEMS chain.

Is Orchard View Manor safe?

Orchard View Manor has documented safety concerns including 7 immediate jeopardy citations. Families should ask about corrective actions taken.

Do nurses at Orchard View Manor stick around?

Orchard View Manor has average staff turnover at 31%, which is typical for the nursing home industry.

Was Orchard View Manor ever fined?

Yes, Orchard View Manor has been fined $219,881 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is Orchard View Manor on any federal watch list?

No, Orchard View Manor is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at Orchard View Manor?

Medicare inspectors have found 64 deficiencies at Orchard View Manor: 7 critical, 6 serious, 50 moderate, 1 minor. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting Orchard View Manor?

Families visiting Orchard View Manor should ask about what corrective actions were taken after fines, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does Orchard View Manor compare to other nursing homes?

Orchard View Manor has a 1-star overall rating, which is below average compared to other nursing homes in RI. Families should carefully review inspection findings and consider alternatives.

Orchard View Manor | 0/100 (Grade F)

Sept 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, family, and staff interview, it has been determined that the facility failed to provide approp...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, family, and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 1 resident reviewed who sustained a fall, Resident ID #2.Findings are as follows:During the investigation of a community reported complaint on 9/24/2025, a surveyor interview was completed at 8:38 AM with Resident ID #2's family member. The family member alleged that Resident ID #2 fell on Friday, 9/19/2025, and was sent to the hospital on 9/21/2025, where s/he was diagnosed with a spinal fracture. The family further revealed that when they questioned the nurse on Sunday about the fall, the nurse revealed that there was no fall documented in Resident ID #2's medical record.Review of a policy titled, Fall Management states in part, .A fall risk evaluation will be conducted by the ‘nurse on duty/supervisor' on any resident/patient sustaining a fall with or without injury.Post fall, once a resident/patient is clinically evaluated as being stable, vital signs, neurological signs, range of motion, and evaluation of cognitive status will be documented. Neurological checks are to be documented on the neurological flow sheet for 72 hours in the following circumstances: resident/patient states that he/she hit head, physical evidence resident hit head, and unwitnessed fall. Resident/patient should continue to be monitored for 72 hours after a fall evaluation for latent injury, with documentation in the medical record.Review of a policy titled, Condition: Significant Change states in part, .The physician, resident/patient and/or responsible party will be notified by the nurse in the event of a change in condition.This notification shall be documented in the clinical record.Record review revealed the resident was readmitted to the facility in May of 2024 with diagnoses including, but not limited to, unsteadiness on feet and history of falling. Record review revealed a Minimum Data Set assessment dated [DATE] which revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition.During a surveyor interview with the resident on 9/24/2025 at 10:31 AM, s/he revealed that on Friday, 9/19/2025 s/he had fallen from his/her wheelchair to the floor, landed on his/her butt and staff members picked him/her back up. S/he further revealed s/he did not have pain at that moment but that it developed the next day. Lastly, s/he revealed that s/he went to the hospital on Sunday because s/he was in so much pain it hurt to move. Record review of the resident's medical record from Friday, 9/19/2025 failed to reveal documentation of a fall occurring, an assessment of the resident including initial vital signs and initial neurological checks, 72-hour vital signs and neurological checks, 72-hour monitoring after a fall for latent injury and/or notification to a provider about a fall per the facility policy. Review of the Medication Administration Record revealed that the resident received Acetaminophen 1000 milligrams (mg) for pain of a six out of ten on 9/20/2025 and nine out of ten pain on 9/21/2025.Review of a progress note dated 9/21/2025 at 9:34 AM Central Standard Time, authored by an on-call provider, revealed that the resident had a fall on Friday where s/he fell from his/her wheelchair and onto the floor on his/her bottom. At that time, s/he reported no pain. The progress notes further revealed that on 9/20 and 9/21/2025, the resident was having pain when moving and complained of 10 out of 10 pain to his/her lower back. Additionally, the progress note revealed that the resident is not able to get out of bed or lift his/her head up without excruciating pain to the back area. His/her baseline is up and out of bed often. The resident is almost in tears on exam from pain.Review of a progress note dated 9/21/2025 at 11:45 AM, authored by Licensed Practical Nurse, Staff A, revealed she overheard the resident screaming in his/her room. Upon entry, the resident stated that s/he had back pain. Staff A revealed that, .upon entering the room resident was lying in bed crying, reports pain localized to lower back rated 10/10. When asked what happened resident stated [s/he] had slipped and fell out of wheelchair Friday 9/19/25. Residents' roommate also stated ‘[s/he] fell out of [his/her] wheelchair the other day'. [range of motion] in lower extremities elicits pain/discomfort during flexion and extension. Redness and warmth area noted in lower back. No swelling or open areas noted.Review of a hospital Discharge summary dated [DATE], revealed that the resident had a compression fracture (a type of break in the vertebrae that causes the bone to collapse) of the L2 vertebrae (a bone in your lumbar region). Further review of the discharge summary revealed that the cause of a compression fracture includes, but is not limited to, a fall or trauma.Record review revealed a physician's order dated 9/23/2025 for tramadol (a narcotic medication used for pain management) 25 mg, to be administered twice daily for pain for 1 week.Review of a statement provided by Nursing Assistant (NA), Staff B, revealed that Resident ID #2 fell on the floor on 9/19/2025 and she helped him/her up to his/her chair with another NA and nurse.During a surveyor interview on 9/24/2025 at 10:19 AM with Staff B, she revealed that on Friday, 9/19/2025, she was standing at the nurse's station when she heard screaming. She entered Resident ID #2's room and found him/her on the floor. The resident stated to Staff B that s/he had fallen and landed on his/her butt. The resident did not complain of pain at that time.During an interview on 9/24/2025 at 12:04 PM, with Registered Nurse, Staff C, she stated that she was the assigned nurse for Resident ID #2 on 9/19/2025. She reported that Staff B informed her the resident was found on the floor but claimed the resident had not fallen. When the surveyor asked whether she had questioned the resident about the incident, Staff C admitted she had not, noting that the resident was crying and appeared frightened. She further acknowledged that she did not perform an assessment or notify the provider regarding the incident.During a surveyor interview on 9/24/2025 at 12:56 PM, with the Director of Nursing Services, she revealed that regardless of if the resident fell from his/her wheelchair or was placed on the floor, that it is still considered a fall. Additionally, she was unable to provide evidence that the resident was evaluated following the fall on 9/19/2025, per the facility policy. Further, she was unable to provide evidence that the provider was notified of the resident's fall until the resident was observed in excruciating pain two days after the fall occurred.

Sept 2025 1 deficiency

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, it has been determined that the facility failed to ensure that residents ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, it has been determined that the facility failed to ensure that residents who require dialysis (a treatment that filters waste and excess fluid from your blood when your kidneys are failing) receive services consistent with professional standards of practice, for 2 of 2 residents reviewed who receive dialysis, Resident ID #s 1 and 3. Findings are as follows: According to the manufacturer's instructions for Sevelamer Carbonate states in part, .1 INDICATIONS AND USAGE Sevelamer Carbonate is indicated for the control of serum phosphorus [elevated levels can develop weak and broken bones and cause damage to blood vessels] in adults .with chronic kidney disease (CKD) on dialysis. 2 DOSAGE AND ADMINISTRATION .administered orally with meals .12.1 By binding phosphate in the gastrointestinal tract and decreasing absorption, sevelamer carbonate lowers the phosphate concentration in the serum (serum phosphorus).1. Record review revealed Resident ID #1 was admitted to the facility in August of 2025 with a diagnosis including, but not limited to, CKD. Additionally, the resident receives dialysis three times a week.Record review revealed the following physician's orders:-8/28/2025, Sevelamer Carbonate 1600 milligrams (mg) by mouth three times a day. -1000 milliliter (ml) fluid restriction (the limitation of daily fluid intake for patients who can't maintain their body's fluid balance) per day; 600 ml from dietary and 400 ml from nursing Review of the August 2025 Medication Administration Record (MAR) from 8/23/2025 through 8/31/2025 revealed the administration times for Sevelamer were scheduled for 6:30 AM, 3:00 PM and 8:00 PM. Further review of the MAR revealed documentation of a code 3, indicating the resident was absent from the facility and that s/he was not administered his/her Sevelamer on 8/26/2025 and 8/27/2025 at 3:00 PM.Further review of the September 2025 MAR revealed the administration times for Sevelamer are scheduled for 8:00 AM, 12:00 PM and 5:00 PM. Further review of the MAR revealed documentation of a code 3, indicating the resident was not administered his/her Sevelamer on the following dates and times:-9/3/2025 at 12:00 PM-9/5/2025 at 8:00 AM-9/10/2025 at 12:00 PM-9/15/2025 at 12:00 PMRecord review of the September 2025 MAR revealed the resident exceeded his/her ordered fluid intake specific to nursing administration, on the following dates:-9/13/2025, 1400 ml-9/14/2025, 1210 ml-9/15/2025, 1010 ml2. Record review revealed Resident ID #3 was readmitted to the facility in August of 2021 with a diagnosis including, but not limited to, CKD. Additionally, the resident receives dialysis three times a week.Record review of a Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating the resident is cognitively intact.Record review revealed the following physician's orders:-8/13/2025, Sevelamer Carbonate 1600 mg by mouth three times a day before meals. -1000 ml fluid restriction per day; 720 ml from dietary and 280 ml from nursing. Review of the August 2025 MAR from 8/13/2025 through 8/31/2025 and the September 2025 MAR revealed the administration times for Sevelamer are scheduled for 7:00 AM, 11:30 AM and 4:30 PM. Further review of the MAR revealed documentation of a code 3, indicating the resident was not administered his/her Sevelamer on the following dates at 11:30 AM:-8/14/2025-8/16/2025-8/19/2025-8/21/2025-8/23/2025-8/26/2025-8/28/2025-9/2/2025-9/4/2025-9/6/2025-9/9/2025-9/11/2025-9/13/2025Record review of the September 2025 MAR revealed the resident exceeded his/her ordered fluid intake specific to nursing administration, on the following dates:-9/8/2025, 1090 ml-9/12/2025, 1040 ml-9/14/2025, 1510 mlDuring a surveyor interview on 9/17/2025 at 5:16 PM with Resident ID #3, s/he revealed that s/he is supposed to receive the Sevelamer before meals and that usually does not happen. The resident further revealed that s/he is good at following his/her fluid restriction. During surveyor interviews with the Director of Nursing Services on 9/17/2025 at 4:19 PM and at 5:30 PM, she was unable to provide evidence that Resident ID #s 1 and 3 received his/her Sevelamer, as ordered, or that the residents' fluid restrictions were followed, as ordered.

Aug 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0776 (Tag F0776)

Could have caused harm · This affected 1 resident

**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 provide or obtain radiology servic...

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**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 provide or obtain radiology services to meet the needs of its residents relative to obtaining a STAT (diagnostic or therapeutic procedure that is to be performed immediately) X-ray for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows:Record review of a facility reported incident dated 8/11/2025 revealed that Resident ID #1 sustained a fall on 8/9/2025 and was admitted to the hospital on [DATE] with a hip fracture.Record review revealed that the resident was admitted to the facility in July of 2023 with diagnoses including, but not limited to, dementia, anxiety, unsteadiness on feet and lack of coordination.Record review of a progress note dated 8/9/2025 authored by the Doctor of Osteopathic Medicine (DO), Staff A, at 4:40 PM revealed that the resident sustained an unwitnessed fall. Additionally, it revealed that the resident complained of right groin pain and demonstrated a leg length discrepancy (right leg shorter than the left). The note further stated, High possibility of right hip fracture and revealed new orders to obtain a STAT right hip X-ray and to remain on bed rest pending results. Record review revealed an order was entered on 8/9/2025 at 4:49 PM for a STAT X-Ray of the resident's right hip.Record review of a nursing progress note dated 8/10/2025 at 6:39 AM revealed that the resident asked what they were going to do for his/her leg, and s/he was told by nursing staff that the facility was going to obtain an X-ray and that s/he was to stay in bed.Record review of a nursing progress note dated 8/10/2025 at 9:29 AM revealed that the contracted company used for X-rays was contacted regarding the STAT X-ray and was told that they would have a technician call the facility with an estimated time of arrival.Record review of a progress note dated 8/10/2025 authored by the Advanced Practice Registered Nurse (APRN), Staff B, at 12:34 PM revealed that they were contacted by nursing staff related to the resident experiencing an acute onset of malaise (a general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify) and fever.Record review of a nursing progress note dated 8/10/2025 at 3:51 PM revealed that the resident had an elevated temperature, and his/her oxygen level was at 75% on room air (normal oxygen levels range from 95%-100%), the resident was placed on oxygen at 2 liters (L) and was given Tylenol which had no effect as the resident continued to have an elevated temperature after one hour. The note further revealed that the provider gave orders for a medical work-up that included lab work, a chest X-ray and a urine analysis.Additional review revealed that while attempting to wash the resident, [s/he] was screaming in pain and unable to roll over to place brief under. when rechecking [resident's] vitals low grad fever persist, and [resident] remained at 90% 3L Nasal Canula. On call provider called again to update on [resident's] status orders were given to send [resident] to Hospital.Review of an ED Provider Note dated 8/10/2025 states, .Per [his/her] nursing facility, [s/he] fell.around 4pm yesterday. This was an unwitnessed fall.was supposed to get an x-ray done of [his/her] right hip but the facility was unable to get this done. They also noted.a low-grade fever this morning.here for evaluation.walks with a walker at baseline and has not been ambulatory since the fall.does have significant hip pain in the setting of an acute hip fracture.During a surveyor interview on 8/13/2025 at approximately 10:40 AM with Licensed Practical Nurse, Staff C, she revealed that that a STAT X-ray should be performed within 4 hours of being ordered by the provider. She further revealed that if the X-ray is not performed in a few hours that the provider would be updated, and the resident could be sent to the hospital.During a surveyor interview on 8/13/2025 at 11:40 AM with the NP, Staff D, he revealed that he would expect the x-ray to be performed the same day if ordered STAT. Additionally, he would expect to be notified if the X-ray could not be performed and if there was a concern for injury the resident would be sent to the hospital for treatment.During a surveyor interview on 8/13/2025 at approximately 11:25 AM with the Director of Nursing Services, she was unable to provide evidence that the facility obtained radiology services to meet the needs of Resident ID #1. Additionally, she acknowledged that the staff did not notify the provider of the delay in obtaining the STAT X-ray on 8/9/2025 resulting in the residents prolonged pain and requiring hospitalization on 8/10/2025. She further revealed that timeliness of X-rays and services has been an ongoing problem with the current contracted company.

Jun 2025 9 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Deficiency F0760 (Tag F0760)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to e...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to ensure that residents are free from significant medication errors for 1 of 1 resident reviewed for the use of methadone (a medication prescribed to reduce cravings and withdrawals from opiates and to treat chronic and severe pain), Resident ID #330. Findings are as follows: Record review of an untitled facility medication reconciliation policy last revised August 2022, states in part, .This facility reconciles medication frequently throughout a resident's stay to ensure the resident is free of significant medication errors .medication reconciliation refers to the process of verifying the resident's current medication list matches the physician's orders for the purposes of providing the correct medications to the resident .medication reconciliation involves collaboration with the resident/representative and multiple disciplines .admission process .Compare orders to the hospital record, etc. Obtain clarification orders as needed . Review of the [NAME] Drug Guide for Nurses last revised January 2021, states in part, .methadone .the duration of methadone withdrawal varies from person to person but may last anywhere from two to three weeks to up to six months .initial withdrawal symptoms are usually mild and may include anxiety, restlessness, a runny nose, sweating, tiredness, and watery eyes .other withdrawal symptoms such as muscle cramps .diarrhea and depression are likely to be at their worst over the first week . During surveyor observations and simultaneous interviews with the resident on 6/24/2025 at 9:45 AM and 6/26/2025 at 10:23 AM, s/he was observed sitting in a chair in his/her room holding his/her back. The resident indicated that his/her pain medication was abruptly changed by NP, Staff H and that s/he was experiencing withdrawal symptoms and increased pain which s/he felt was abusive and harmful. When asked what symptoms s/he was experiencing, s/he indicated that s/he experiencing withdrawal symptoms that included increased body aches, depression, diarrhea, abdominal pains, and sweating. Record review revealed Resident ID #330 was admitted to the facility on [DATE] with diagnoses including, but not limited to, osteomyelitis of vertebra (an infection and inflammation of the bone and bone marrow that affects the spine), opiate dependence, anxiety, and depression. Record review of a Brief Interview of Mental Status assessment dated [DATE], revealed a score of 13 out of 15, indicating intact cognition. Record review of a hospital document titled, Continuity of Care [COC] - Post-Acute Facility dated 6/18/2025 revealed that the resident presented to the hospital with low back pain and was found to have recurrent osteomyelitis. Additionally, s/he was to continue on oxycodone (an opioid medication prescribed to treat moderate to severe pain), 10 milligrams (mg) every six hours as needed for severe pain, and a daily dose of Methadone 105 mg upon discharge from the hospital. -6/19/2025 documented as a late entry and authored by NP, Staff I, states in part, The patient had requested to speak with the provider discussed pain management .confirmed with the patient that .was discharged to the facility to be given oxycodone every 6 hours PRN .became notably upset, started crying; stated I cannot function because of the pain' .provider compromised with patient to give oxycodone every 4 hours as needed for short term basis .there were some questions regarding the actual dose and they were reaching out to the pain clinic to confirm the dose .patient will continue on ordered dose for now we will continue to monitor for acute changes/signs and symptoms of withdrawal at the facility .continue methadone 52 MG given by mouth every 12 hours . Additional record review failed to reveal evidence that the order for methadone 52 mg every 12 hours was transcribed on 6/19/2025 as ordered. Record review revealed the methadone order was transcribed to administer 52 mg by mouth one time a day in error, rather than every 12-hours as ordered by the provider. Further record review failed to reveal evidence that the resident was being monitored for withdrawal symptoms. Review of the June 2025 Medication Administration Record (MAR) revealed the resident did not receive 52 mg of methadone every 12 hours as ordered on the following dates: 6/19/2025 6/20/2025 Record review revealed a physician's order with a start date of 6/19/2025 for oxycodone 10 milligrams every four hours as needed. Additional review of the June 2025 MAR revealed the resident received the oxycodone 10 mg for pain on the following dates and times: -6/19/2025 at 8:16 PM, Pain documented as 7 out of 10, indicating severe pain. -6/20/2025 at 12:16 AM, Pain documented as 10 out of 10, indicating severe pain. -6/20/2025 at 6:00 AM, Pain documented as 10 out of 10, indicating severe pain. -6/20/2025 at 12:24 PM, Pain documented as 7 out of 10, indicating severe pain. -6/20/2025 at 5:30 PM, Pain documented as 7 out of 10,indicating severe pain. -6/20/2025 at 9:40 PM, Pain documented as 7 out of 10, indicating severe pain. -6/21/2025 at 2:27 AM, Pain documented as 7 out of 10, indicating severe pain. Review of a progress note dated 6/20/2025 revealed that the resident was seen by NP, Staff H, and an order was provided to increase the resident's dose of methadone to 105 mg daily, which reflects the intended dose upon the resident's admission. During a surveyor interview 6/25/2025 12:02 PM with NP, Staff I, she revealed that on 6/19/2025 she gave a verbal order for methadone 52 mg every 12 hours and it was her expectation that the resident was to receive the methadone as ordered. Further, she indicated she would have expected the facility to monitor the resident for signs and symptoms of withdrawal symptoms. During surveyor interviews on 6/25/2025 at 12:15 PM and 6/26/2025 at approximately 4:00 PM, with the Director of Nursing Services, she indicated it would be her expectation that the resident would have received methadone 52 mg twice daily as ordered by NP, Staff I. Additionally, she was unable to provide evidence that the resident was kept free from significant medication errors. Cross reference F697 and F835.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to e...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to ensure that adequate pain management was provided to a resident who required such services, for 1 of 1 resident reviewed for pain, Resident ID #330. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 6/25/2025 indicates the resident reported to the state surveyor s/he was abused by the Nurse Practitioner (NP), Staff H, related to changes in his/her medications. Record review of an untitled facility policy relative to medication reconciliation, last revised in August of 2022, states in part, .This facility reconciles medication frequently throughout a resident's stay to ensure the resident is free of significant medication errors .medication reconciliation refers to the process of verifying the resident's current medication list matches the physician's orders for the purposes of providing the correct medications to the resident .medication reconciliation involves collaboration with the resident/representative and multiple disciplines .admission process .Compare orders to the hospital record, etc. Obtain clarification orders as needed . Review of the [NAME] Drug Guide for Nurses last revised January 2021 states in part, .methadone .the duration of methadone withdrawal varies from person to person but may last anywhere from two to three weeks to up to six months .initial withdrawal symptoms are usually mild and may include anxiety, restlessness, a runny nose, sweating, tiredness, and watery eyes .other withdrawal symptoms such as muscle cramps .diarrhea and depression are likely to be at their worst over the first week . Record review revealed Resident ID #330 was admitted to the facility on [DATE] with diagnoses including, but not limited to, osteomyelitis of the vertebra (an infection and inflammation of the bone and bone marrow that affects the spine), opiate dependence, anxiety, and depression. Record review of a Brief Interview of Mental Status assessment dated [DATE], revealed a score of 13 out of 15, indicating intact cognition. During surveyor observations and simultaneous interviews with the resident on 6/24/2025 at 9:45 AM and 6/26/2025 at 10:23 AM, s/he was observed sitting in a chair in his/her room holding his/her back. The resident indicated that his/her pain medication was abruptly changed by NP, Staff H and that s/he was experiencing withdrawal symptoms and increased pain which s/he felt was abusive and harmful. When asked what symptoms were experienced, s/he indicated she was experiencing withdrawal symptoms that included increased body aches, depression, diarrhea, abdominal pains, and sweating. Review of a hospital document titled, Continuity of Care [COC] - Post-Acute Facility dated 6/18/2025 revealed that the resident presented to the hospital with low back pain and was found to have recurrent osteomyelitis. Additionally, s/he was to continue oxycodone (an opioid medication prescribed to treat moderate to severe pain) (10 milligrams [mg]) one tablet every six hours as needed for severe pain, and a daily dose of Methadone 105 mg upon discharge from the hospital. Record review of a progress note dated 6/19/2025 documented as a late entry and authored by NP, Staff I, states in part, The patient had requested to speak with the provider discussed pain management .confirmed with the patient that .was discharged to the facility to be given oxycodone every 6 hours PRN .became notably upset, started crying; stated 'I cannot function because of the pain' .provider compromised with patient to give oxycodone every 4 hours as needed for short term basis .there were some questions regarding the actual dose and they were reaching out to the pain clinic to confirm the dose .patient will continue on ordered dose for now we will continue to monitor for acute changes/signs and symptoms of withdrawal at the facility .continue methadone 52 MG given by mouth every 12 hours. Record review revealed a physician's order dated 6/18/2025 for Methadone 52 mg by mouth one time a day. Indicating the order was not transcribed to be administered every 12 hours as intended by the provider. Additional record review failed to reveal evidence that the resident was being monitored for withdrawal symptoms. Review of the June 2025 Medication Administration Record (MAR) revealed the resident received 52 mg of methadone once daily on the following dates and times: 6/19/2025 at 8:00 AM 6/20/2025 at 8:00 AM Record review revealed a physician's order with a start date of 6/19/2025 for oxycodone 10 mg one tablet every four hours as needed Additional review of the June 2025 MAR revealed the resident received the oxycodone 10 mg for pain on the following dates and times: -6/19/2025 at 8:16 PM, Pain documented as 7 out of 10, indicating severe pain. -6/20/2025 at 12:16 AM, Pain documented as 10 out of 10, indicating severe pain. -6/20/2025 at 6:00 AM, Pain documented as 10 out of 10, indicating severe pain. -6/20/2025 at 12:24 PM, Pain documented as 7 out of 10, indicating severe pain. -6/20/2025 at 5:30 PM, Pain documented as 7 out of 10, indicating severe pain. -6/20/2025 at 9:40 PM, Pain documented as 7 out of 10, indicating severe pain. -6/21/2025 at 2:27 AM, Pain documented as 7 out of 10, indicating severe pain. Review of a progress note dated 6/20/2025 revealed that the resident was seen by NP, Staff H, and an order was provided to increase the resident's dose of methadone to 105 mg daily, which reflects the intended dose upon the resident's admission. Additional review of the June 2025 Medication Administration Record (MAR) revealed the resident received an as needed dose of methadone 52 mg on 6/21/2025. Further review failed to reveal evidence that the order for the resident to receive 105 mg daily was transcribed into his/her record. Lastly an order for the resident to receive 52 mg of methadone every 12 hours was entered into their MAR on 6/22/2025 at 8:00 AM. During a surveyor interview 6/25/2025 12:02 PM with NP, Staff I, she revealed that on 6/19/2025 she gave a verbal order for methadone 52 mg every 12 hours and it was her expectation that the resident was to receive the methadone as ordered. Further, she indicated she would have expected the facility to monitor the resident for signs and symptoms of withdrawal symptoms. During surveyor interviews on 6/25/2025 at 12:15 PM and on 6/26/2025 at approximately 4:00 PM, with the Director of Nursing Services, she indicated it would be her expectation that the resident would have received methadone 52 mg twice daily as ordered. Additionally she was unable to provide evidence that the facility managed Resident ID #330's pain adequately. Cross reference F760 and F835.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Administration (Tag F0835)

Could have caused harm · This affected 1 resident

**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 be administered in a manner that ...

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**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 be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident relative to 1 of 1 resident reviewed with an order for methadone (a medication prescribed to reduce cravings and withdrawals from opiates and to treat chronic and severe pain), Resident ID #330. Findings are as follows: Record review of an untitled facility policy relative to medication reconciliation, last revised in August of 2022 states in part, .This facility reconciles medication .to ensure that the resident is free of any significant medication errors .'Medication reconciliation' refers to the process of verifying that the resident's current medication list matches the physician's orders for the purposes of providing the correct medications to the resident .Medication reconciliation involves . multiple disciplines, including admission liaisons, licensed nurses, physicians, and pharmacy staff .Pre-admission Process .obtain current medication list from referral source .obtain current medication/admission orders .forward to nursing unit accepting the resident .admission Process .Compare orders to hospital records .Obtain clarification orders as needed .Transcribe orders in accordance with procedures for admission orders .have a second nurse review transcribed orders for accuracy .order medications from pharmacy in accordance with facility policy for ordering medications .Verify medications received match the medication orders . Review of the facility's Memorandum of Agreement with Codac (an outpatient supplier who provides methadone for residents residing in this facility), states in part, .Duties and Responsibilities .Ensuring that referrals made, one to the other, are appropriate, and supported by an accurate summary of .recommendations .Once the patient has arrived at the Offsite facility, the Offsite facility will fax Referral/Discharge form . Review of the [NAME] Drug Guide for Nurses last revised January 2021, states in part, .methadone .the duration of methadone withdrawal varies from person to person but may last anywhere from two to three weeks to up to six months .initial withdrawal symptoms are usually mild and may include anxiety, restlessness, a runny nose, sweating, tiredness, and watery eyes .other withdrawal symptoms such as muscle cramps .diarrhea and depression are likely to be at their worst over the first week . Record review revealed Resident ID #330 was admitted to the facility in June of 2025 with a diagnosis including, but not limited to, opioid use. Record review revealed a Brief Interview for Mental Status score of 13 out of 15, indicating intact cognition. During a surveyor interview on 6/24/2025 at 9:45 AM with Resident ID #330, s/he indicated that his/her pain medication was abruptly changed after their admission to the facility. The resident further indicated that s/he experienced symptoms of withdrawals due to this change and that s/he felt this was abusive and harmful. Record review of the Printable Discharge Form dated 6/18/2025 revealed communication between a hospital employee and the Admissions Coordinator, an unlicensed employee of the facility, at 9:57 AM, prior to Resident ID #330's admission. Further review of this document revealed the hospital employee wrote, .last methadone today at 8:54 am 52.5 mg [milligrams] . Record review of a form completed by the Admissions Coordinator dated 6/18/2025 revealed the .Amount of Last Methadone Dose was written is as 52.5 mg. Other Pertinent Information was left blank. The physician's order was not included on this communication form. Record review revealed this form was faxed to Codac on 6/18/2025 at 9:12 AM and at 9:16 AM. Record review of the hospital Continuity of Care form dated 6/18/2025, revealed the resident was ordered 105 mg of Methadone daily. Record review of the hospital discharge medication list dated 6/18/2025 revealed a physician's order for Methadone 105 mg daily. Record review of the June 2025 Medication Administration Record revealed that the resident received Methadone 52.5 mg once on 6/18 (in the hospital) and Methadone 52 mg on 6/19 and 6/20 in the facility, less than half of his/her prescribed dose. Record review of a facility document titled, Reconciliation of New admission Medication from Continuity of Care Form dated 6/18/2025 revealed two nurses signed that the medications had been reviewed with a physician. Further review revealed a handwritten note to Confirm Methadone Dosage. During a surveyor interview on 6/25/2025 at 12:02 PM with Nurse Practitioner, Staff I, she indicated that she was unaware that the resident was only receiving half of the ordered dose of Methadone. She further indicated that she ordered 52 mg twice daily and would have expected the resident to receive that dose. During a surveyor interview on 6/25/2025 at approximately 12:10 PM with the Admissions Coordinator, she indicated that she communicated with the care manager at the hospital via telephone and requested the resident's Methadone order. She further indicated that the hospital sent what she thought was the Methadone order electronically, which indicated the resident's last dose was 52.5 mg. Additionally, she indicated that she completed the form with the dose of 52.5 mg and sent it to Codac for the prescription to be filled. Furthermore, she indicated that she is not a licensed nursing professional and transcribed the resident's last dose of Methadone that had not been reconciled by a nurse or provider. During a surveyor interview on 6/25/2025 at 12:15 PM with the Director of Nursing Services, she acknowledged that the Admissions Coordinator, an unlicensed employee, transcribed what she thought to be, the resident's Methadone order on the form that was sent to Codac to be filled and delivered to the facility. Additionally, she acknowledged that this is the practice of the facility. Furthermore she acknowledged that the resident was not present in the facility prior to his/her prescription being sent to Codac to be filled, which does not align with the facility's Memorandum of Agreement with Codac. Lastly, she acknowledged that the Methadone prescription was not reconciled by a physician or a licensed nurse prior to being forwarded to Codac to be filled on 6/18/2025, per the facility's policy. The facility's failure to follow the Memorandum of Agreement with Codac and to have a licensed nurse and/or a provider reconcile the Methadone order prior to it being forwarded to Codac to be filled, resulted in the resident receiving half of their prescribed dose of Methadone. This failure caused the resident to experience withdrawal symptoms. Cross reference F697 and F760

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to e...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to ensure that the resident's environment remained as free of accident hazards as possible for 3 of 4 shower rooms observed relative to safety rails (rails that provide a sturdy handhold to help users maintain balance and avoid slips and falls, especially on wet or slippery surfaces). Findings are as follows: 1a. During a surveyor interview on 6/24/2025 at approximately 1:15 PM with Resident ID #71, s/he stated that the shower rails are loose and when s/he went to stand in the shower the other day, the safety rail gave out. Record review revealed Resident ID #71 was admitted to the facility in April of 2025 with diagnoses including, but not limited to, lack of coordination and unsteadiness on feet. Review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 out of 15, indicating intact cognition. Review of the task documentation revealed that the resident is frequently independent with showers. During a simultaneous surveyor observation of the [NAME] Unit shower room and interview with Nursing Assistant (NA), Staff A, on 6/24/2025 at 1:27 PM, he acknowledged that two of the three shower stalls had safety rails that were detached from the shower walls. He indicated that he had been aware of the unstable shower safety rails since he started working on that unit, approximately one month ago. During a subsequent surveyor observation on 6/25/2025 at 3:23 PM, of the shower room on the [NAME] Unit, the safety rail to the right side of the toilet was observed to be loose. During a surveyor interview immediately following the above observation with NA, Staff B, she acknowledged that the safety rail to the right side of the toilet was loose. 1b. During a surveyor observation on 6/24/2025 at 1:22 PM of the shower room on the [NAME] Unit, two of the three shower stalls were observed to have loose safety rails, which were rusted. Additional observations revealed the safety rail to the left side of the toilet was loose. During a surveyor interview on 6/24/2025 at 1:26 PM with NA, Staff C, she indicated that all three of the shower stalls are utilized by the residents. Additionally, she acknowledged that two of the shower stalls had safety rails that were loose, as well as the safety rail near the toilet. During a surveyor interview on 6/24/2025 at 1:29 PM with Licensed Practical Nurse (LPN), Staff D, she indicated that at least one resident on the unit prefers to stand in the shower and may use the loose bars. Additionally, she indicated that she was unaware of the unstable safety rails in the shower room. 1c. During a surveyor observation on 6/24/2025 at approx. 2:35 PM, of the shower room on the Cortland Unit, two of three shower stalls were observed to have loose safety rails, which were rusted, one of which was completely detached from the wall. During a surveyor interview on 6/24/2025 at 2:40 PM with NA, Staff E, she indicated that two of the three shower stalls had loose safety rails. She further indicated that at least two residents on the unit prefer to stand in the shower. During a surveyor interview on 6/24/2025 at 2:48 PM with Registered Nurse, Staff F, she acknowledged that the safety rails are loose in two of the shower stalls and one is detached in the middle shower stall. Additionally, she acknowledged that some residents prefer to stand while utilizing those showers. During a surveyor interview on 6/25/2025 at 3:32 PM, with Maintenance Staff, Staff G, he acknowledged the loose and detached safety rails in the shower rooms on the [NAME], [NAME], and Cortland Units. Additionally, he indicated that he was unaware of the loose and detached rails, and would have expected staff to notify maintenance of anything in disrepair within the facility.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmiss...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to staff wearing the appropriate personal protective equipment (PPE), for 1 of 1 resident observed on neutropenic precautions (a set of measures taken to prevent infections for individuals with neutropenia, a condition where there is an abnormally low number of white blood cells, increasing the risk of infection), Resident ID #2, and for 1 of 1 resident reviewed who was readmitted to the facility with an order for Enhanced Barrier Precautions (EBP; infection control measures which require putting on a gown and gloves during high-contact resident care activities), Resident ID #43. Findings are as follows: 1. Review of a facility policy titled, Neutropenic Precautions states in part, .if an order is received to place a resident on neutropenic precautions, the nurse will clarify what restrictions are necessary .staff members will wear a mask with any direct contact with the resident .provide a supply of masks, gowns, gloves .needed to maintain isolation precautions . Record review revealed Resident ID #2 was admitted to the facility in February of 2023. Record review revealed a physician's order dated 3/29/2023 for Neutropenic Precautions every shift for neutropenia. During a surveyor interview on 6/23/2025 at 10:45 AM with Licensed Practical Nurse (LPN), Staff D, she indicated that she was unaware of the reason why Resident ID #2 was on neutropenic precautions. She further indicated that staff are expected to wear a mask, gown, and gloves upon entering the resident's room. During a surveyor observation on 6/23/2025 at 10:52 AM, Nursing Assistant (NA), Staff K, entered Resident ID #2's room. Staff K failed to perform hand hygiene or put on a gown or gloves. Additionally Staff K, wore her mask on her chin, leaving her nose and mouth exposed while assisting the resident in bed. During a surveyor interview on 6/23/2025 at 10:56 AM with Staff K, she acknowledged that she did not wear a gown or gloves and wore her mask below her nose and mouth while assisting Resident ID #2 in bed. She further indicated that the resident was not on any precautions, however, acknowledged that there was signage and a precautions bin outside of the resident's room. During a subsequent surveyor observation on 6/23/2025 at 11:09 AM following the above interview, Staff K re-entered the resident's room without performing hand hygiene, putting on a mask, gown or gloves, and leaned over the resident to talk to him/her and delivered a cup of ice. During a surveyor interview on 6/23/2025 at 11:25 AM with LPN, Staff D, she acknowledged that the resident is immunocompromised and that the neutropenic precautions are in place to protect the resident from infections. During a surveyor interview on 6/25/2025 at approximately 11:20 AM with the Infection Preventionist (IP) in the presence of the Director of Nursing Services (DNS), she indicated that she would expect all staff to wear a mask, gown, and gloves each time they enter Resident ID #2's room. 2. Review of a facility policy titled, .Policy for Enhanced Barrier Precautions states in part, .implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms [MDROs] .additional epidemiological important MDROs may include, but are not limited to .ESBL-producing Enterobacterales [a group of bacteria that commonly cause infections .are resistant to common antibiotics and may require complex treatments] .require the use of gown and gloves .during specific high-contact resident care activities in which there is an increased risk for transmission of [MDROs]. High-contact resident activities include bathing/showering, providing hygiene, dressing, transferring, linen changes, toileting, device care and wound care . Record review revealed Resident ID #43 was readmitted to the facility in June of 2025 with diagnoses including, but not limited to, ESBL. Record review revealed a physician's order dated 3/2/2025 for EBP every shift related to a history of ESBL. During surveyor observations on 6/24/2025 at 9:13 AM and at 12:27 PM, of the resident's room failed to reveal a precautions sign or a precautions bin containing personal protective equipment (PPE). During a surveyor observation on 6/24/2025 at 12:28 PM, NA, Staff M, was observed assisting Resident ID #43 in the shower wearing only gloves. During an additional surveyor observation on 6/24/2025 at 12:51 PM, Staff M was observed getting a brief out of the resident's drawer and then grabbing dirty linens off of the resident's bed without wearing a gown or gloves. The dirty linens were observed to be touching Staff M's body as she picked them up and carried them across the room to put them into a bag. During a surveyor interview on 6/24/2025 at 12:52 PM with Staff M, she indicated that she was unaware that the resident was on any precautions. During a surveyor interview on 6/24/2025 at 1:00 PM with LPN, Staff D, she acknowledged that the resident had an active order for EBP related to a history of ESBL. She further acknowledged that the resident did not have a precautions sign or bin outside of his/her room. Additionally, she indicated that she would expect staff to wear a gown and gloves when performing high contact activities such as assisting the resident with a shower or when touching dirty linens. During a surveyor interview on 6/25/2025 at approximately 11:30 AM with the IP, in the presence of the DNS, she acknowledged that Resident ID #43 has an active order for EBP and that she would expect a precaution sign and bin to be placed by the resident's door. She further indicated that she would expect staff to utilize PPE as required.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected multiple residents

Based on surveyor observation and staff interview, it has been determined that the facility failed to maintain all mechanical, electrical, and patient care equipment in a safe operating condition for ...

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Based on surveyor observation and staff interview, it has been determined that the facility failed to maintain all mechanical, electrical, and patient care equipment in a safe operating condition for the exhaust hood in the main kitchen. Findings are as follows: NFPA (National Fire Protection Association) 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 2011 Edition section 11.2 states in part, .11.2.1* Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person (s) acceptable to the authority having jurisdiction at least every 6 months . During a surveyor observation of the main kitchen on 6/23/2025 at 8:20 AM revealed that the exhaust hood over the stove was last cleaned on 6/26/2024. The next required semiannual cleaning would have been due on 12/26/2024, which indicates the cleaning was past due by more than 5 months. During a surveyor interview with the Food Service Director following the above observation, he acknowledged that the exhaust hood failed to receive cleaning at least every 6 months, as required.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0924 (Tag F0924)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it has been determined that the facility failed to have handrails securely af...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it has been determined that the facility failed to have handrails securely affixed to the walls on 3 of 4 units in the facility. Findings are as follows: Surveyor observations on 6/23/2025 revealed the following handrails were not securely affixed to the wall: 1. [NAME] Unit - The handrail between rooms A7 and A9 was falling off the wall, with the screws exposed. - The handrail on right side of the door of room A9 was loose. Resident ID #12 was observed utilizing the handrails in the hallway while self-propelling in a wheelchair to get to his/her room. During a surveyor interview on 6/23/2025 at 2:58 PM with Nursing Assistant, Staff C, she acknowledged that the above-mentioned handrails were loose and not securely affixed to the wall. During a surveyor interview on 6/23/2025 at 3:01 PM with Licensed Practical Nurse (LPN), Staff D, she revealed that she was aware of the broken handrail between rooms A7 and A9, and has notified the maintenance department about it. Additionally, she indicated that repair requests are documented in the maintenance log. Staff D was unable to provide evidence that she had submitted a request for the repair of the hand rail to the maintenance department. Review of the maintenance log, failed to review evidence that a repair request had been submitted. 2. [NAME] Unit - The handrail between rooms B6 and B8 was loose. - The handrail between rooms B10 and B12 was loose. During a surveyor interview on 6/23/2025 at approximately 3:00 PM, LPN, Staff O, she acknowledged that the above-mentioned handrails were loose and indicated they should be secured. 3. Cortland Unit - The handrails outside rooms C18, C20, and C22 were loose. During a surveyor observation and interview on 6/23/2025 at 2:53 PM with the Maintenance Director, he acknowledged that the above-mentioned handrails were loose and needed to be fixed right now. During a surveyor interview on 6/24/2025 at 12:17 PM with the Director of Nursing Services, she revealed that she was aware that the above-mentioned handrails in the facility were broken and loose, and that she would follow up with the Maintenance Director to complete an audit to ensure that all of them are fixed and secured.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure that food is stored...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation 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. Findings are as follows: 1. Record review of Rhode Island Food Code, 2022 Edition, Section 3-501.17 states in part, .READY -TO-EAT-TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees Celsius or 41 degrees Fahrenheit or below for a maximum of 7 days. The day of preparation shall be counted as Day 1 . During the initial tour of the kitchen on 6/23/2025 at approximately 8:20 AM in the presence of the Food Service Director (FSD), the following was observed without a label or a date: In the walk-in refrigerator: - one 3 pounds (lbs.) bag containing potatoes. - seven individually wrapped round packages containing sliced deli turkey meat, approximately 1 lb. each. In the walk- in freezer: -one bag containing approximately 12 frozen skinless, boneless chicken breasts. - one individually wrapped frozen vanilla [NAME] cake. - one clear plastic bag containing approximately 24 frozen raw cookie dough pieces. - a clear bag containing four individual frozen pie crusts. - one tray of 24 frozen biscuits. - one box of 60 frozen individual assorted chocolate candies. - two and a half cylindrical shaped packages, approximately 18 inches long and 3 inches in diameter containing an unidentified food product. In the main kitchen: - one 20-liter clear plastic container with a lid, containing approximately 5 liters of an unidentified white powder. During a surveyor interview with the FSD immediately following the above observations, he acknowledged that the items were not labeled or dated as required per the Food Code. 2. Record review of The Rhode Island Food Code 2022 Edition 4.601.11 reads in part, .(A) equipment food contact surfaces .shall be clean to sight . During a surveyor observation of the facility ice machine located in the main kitchen during the initial tour on 6/23/2025 at approximately 8:50 AM, revealed black matter approximately 3 inches long on the white shield located on the inside of the machine where the ice is dispensed. During a surveyor interview with the FSD immediately following the above observations, he acknowledged the presence of the black matter inside of the ice machine.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected most or all residents

Based on staff interview and record review, it has been determined that the facility failed to maintain an effective pest control program so that the facility is free of pests. Findings are as follows...

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Based on staff interview and record review, it has been determined that the facility failed to maintain an effective pest control program so that the facility is free of pests. Findings are as follows: During the resident council meeting on 6/25/2025 at 10:00 AM, the residents reported the following: - Resident ID #117 complained that someone told him/her that there were cockroaches and ants in his/her room. - Resident ID #s 38 and 95 have seen ants eat their leftover food in their rooms. The following observations were made after the resident council meeting: - 6/25/2025 at 11:03 AM, ants were observed to be present in the rear stairwell. - 6/25/2025 at approximately 12:00 PM and 2:00 PM, ants were observed in the second-floor dining room. - 6/26/2025 at approximately 8:00 AM and 2:00 PM, ants were observed in the second-floor dining room. During a surveyor interview on 6/26/2025 at 2:49 PM with the covering Administrator, he revealed that the facility has not had pest control services since February of 2024. Additionally, he was unable to provide evidence that the facility is kept free of pests.

Apr 2025 4 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality, relative to following a physician's order to obtain daily weights...

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Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality, relative to following a physician's order to obtain daily weights for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, .The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients . Record review revealed a physician's order with a start date of 3/27/2025 for the resident to be weighed daily. Record review failed to reveal evidence of documented weights from 3/28/2025 through 4/1/2025. Additional, record review failed to reveal evidence that the physician was notified of the missed weights. During a surveyor interview on 4/2/2025 at approximately 11:30 AM, with the DNS she was unable to provide evidence that daily weights were obtained for Resident ID #1 from 3/28/2025 through 4/1/2025.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0808 (Tag F0808)

Could have caused harm · This affected 1 resident

Based on record review, surveyor observation, and staff interview, it has been determined that the facility failed to ensure a resident received a therapeutic diet as ordered by the physician for 1 of...

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Based on record review, surveyor observation, and staff interview, it has been determined that the facility failed to ensure a resident received a therapeutic diet as ordered by the physician for 1 of 2 residents reviewed who had orders for a therapeutic diet, Resident ID #1. Findings are as follows: Resident ID #1 was admitted to the facility in March of 2025 with diagnoses including, but not limited to, acute and chronic respiratory failure and diastolic heart failure (when the left ventricle of the heart becomes stiff and does not beat properly). Record review of a physician order with a start date of 3/26/2025 revealed a Low Sodium Diet (2-4 grams of Sodium) diet. During a surveyor observation of the resident on 4/2/2025 at approximately 12:30 PM, revealed that the lunch meal that was served to the resident contained a double portion of ham. Record review of the tray ticket that was on the resident's tray revealed the following in part: - Regular Texture, Low Sodium - Notes: Double Portions - No Ham During a surveyor interview on 4/2/2025 at approximately 2:00 PM with the Dietitian, Staff B, she acknowledged that the prescribed diet was not served to the served to the resident. She further revealed that s/he should have received baked chicken. B. Record review of a physician order dated 3/26/2025 revealed a 2000 milliliters (ml) daily fluid restriction, dietary to provide 830 ml of the 2000 ml fluid restriction. Record review of the tray ticket for 4/2/2025 revealed the following in part: Breakfast: 4 ounces (oz) of Milk 8 oz of Orange Juice Lunch: 8 oz of Cranberry Juice 8 oz of Ginger Ale Dinner 8 oz of Cranberry juice 8 oz of Ginger Ale This indicates that a total fluid amount provided to the resident by the dietary department was 1320 ml's, which exceeded the 830 ml's that is allotted to be provided by the dietary department in a 24 hour period. During a surveyor observation on 4/2/2025 at 12:30 PM of the resident's lunch tray, revealed the resident was provided with 8 ounces of gingerale, that was placed in a 16 ounces styrofoam container of ice, and 8 ounces of cranberry juice. During a surveyor interview with the resident immediately following the above mentioned observation, s/he revealed that s/he placed the gingerale that was on his/her lunch tray into the cup of ice. Additionally, s/he acknowledged that s/he was on a fluid restriction. During a surveyor interview on 4/2/2025 at 1:30 PM, with the Dietitian, Staff B, she indicated that the Dietary staff provide the beverages that are listed on the meal tickets. She acknowledged that beverages listed on Resident ID #1's meal ticket indicates that s/he exceeds his/her daily dietary fluid allotment, as she was receiving 1320 ml from dietary, and should only be receiving 830 ml.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to maintain medical records in accordance with professional standards and pr...

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Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to maintain medical records in accordance with professional standards and practices for 1 of 1 resident reviewed for a fluid restriction and for a complete and accurate medical record, Resident ID #1. Findings are as follows: 1a. Record review of a facility policy titled, Nursing Policy & Procedure Manual, April 2015 reads in part maintain accurate intake and output and no water pitchers are to be left at the bedside. Record review for Resident ID #1 revealed that s/he was admitted to the facility in March of 2025 with diagnoses including, but not limited to, diastolic congestive heart failure (when the left ventricle of the heart becomes stiff and does not beat properly) and acute and chronic respiratory failure. Record review revealed a physician order dated 3/26/2025 for a fluid restriction of 2000 milliliters (ml) daily, to be as administered on the following nursing shifts: - 11:00 PM -7:00 AM 290 ml - 7:00 AM -3:00 PM 440 ml - 3:00 PM -11:00 440 ml - Dietary 830 ml across three meals Surveyor observation on 4/2/2025 at 10:45 AM, revealed the resident was lying in bed with a 16 ounce styrofoam pitcher of water, a 16 ounce styrofoam pitcher of ice and a 16.9 ounce bottle of water at his/her bedside. Record review of the Medication Administrator Records (MAR) for March 2025 and April 2025 failed to reveal evidence of the amount of fluids the resident received during each shift. Further review of the MARs revealed a check mark for the amount of fluids consumed each shift. During a surveyor interview on 4/2/2025 at 2:30 PM, with the Director of Nursing Services she revealed fluid intake amounts are not documented in the medical records with the amount of fluid the resident receives each shift. Additionally, she revealed that outputs are not accurately documented in the medical record per the facility's policy. Furthermore, the DNS she was unable to explain why there was a bottle of water, a styrofoam pitcher of water and a styrofoam pitcher ice at the resident's bedside. 1b.Record review of a care plan that was developed on 3/26/2025 revealed that the resident was assessed as having verbal expressions of anger with others and accusatory behaviors towards staff. Record review revealed the resident was assessed on 3/27/2025 by the facility's social worker and the evaluation revealed that the resident had no behavioral concerns and was adjusting to his/her recent nursing home placement. Record review failed to reveal evidence that the social service assessment completed on 3/27/2025 addressed the care plan concerns that were identified of verbal expressions of anger, anxiety and accusatory behaviors towards staff. During a surveyor interview on 4/1/2025 at approximately 11:00 AM with the DNS she revealed the resident's concerns are addressed every morning at clinical meeting with the team. She indicated the team includes Social Worker, Staff A. During a surveyor interview with Staff A on 4/2/2025 at 11:26 AM, she revealed that she was unaware of any concerns with the resident until this morning when the DNS spoke with her, after the surveyor discussed the resident with the DNS. During a surveyor interview on 4/2/2025 at 11:30 AM, with the DNS she was unable to provide evidence that the resident's medical record was accurately documented.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

Based on surveyor observation, resident and staff interview, it has been determined that the facility failed to maintain a safe, functional, and comfortable environment for residents, staff, and the p...

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Based on surveyor observation, resident and staff interview, it has been determined that the facility failed to maintain a safe, functional, and comfortable environment for residents, staff, and the public, relative to a cracked glass panel on the inner door of the facility's entrance. Findings are as follows: Surveyor observation on 4/2/2025 at approximately 12:30 PM, revealed that upon entering the facility, the lower glass panel of the main vestibule's inner door had approximately eight one foot by one-foot cracked glass segments. Further observation revealed that the cracked glass segments were covered with white medical tape. During a surveyor interview on 4/2/2025 at 2:00 PM with the Director of Nursing Services, she acknowledged the damage to the door. Additionally, she indicated that the damage occurred approximately three to four weeks ago. Furthermore, she was unable to provide evidence of a plan to repair the door.

Mar 2025 1 deficiency

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected multiple residents

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to be adequately equipped to allow residents to call for staff assistance through a c...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area directly from each resident's bedside for 4 of 4 units reviewed, affecting Resident ID #s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 3/24/2025 alleged that 23 residents do not have functioning call lights, and instead utilize a hand bell as an alternative. Additionally, the report alleged that this issue has been ongoing for months posing concerns for the safety of the residents. During a surveyor interview on 3/26/2025 at 9:40 AM and 10:40 AM with the Director of Nursing Services, she revealed that approximately 30 residents do not have functioning call lights and instead, they are provided with hand bells to communicate their needs to the staff. She further revealed that this has been an ongoing issue and provided the surveyor with an undated, untitled document that revealed a list of all 4 units of the facility and the names of the residents that reside on each unit. Additionally, she indicated that any room with the label NCL indicates that there is no call light in the room. Review of the above-mentioned document revealed that 25 rooms listed were labeled with NCL. Additional review revealed that 21 of the 25 rooms were occupied by residents. Further review of the document revealed the following residents resided in rooms with the NCL designation: - A Unit: Resident ID #2 - B Unit: Resident ID #s 1, 5, 6, and 7 - C Unit: Resident ID #s 3, 8, 9, 10, 11, and 12 - D Unit: Resident ID #s 4, 13, 14, 15, 16, 17, 18, 19, 20, and 21 During multiple surveyor observations and subsequent interviews with staff on 3/26/2025 revealed the following residents without a call light in his/her room at the following times: -Resident ID #1, who resides on the B Unit, at 11:12 AM. Additionally, Registered Nurse, Staff A, acknowledged that there was no call light and revealed he does not recall there being a call light. -Resident ID #2, who resides on the A Unit, at 11:43 AM. Additionally, Medication Technician, Staff B, acknowledged that there was no call light and revealed she was unsure how long the resident has not had a call light. -Resident ID #3, who resides on the C Unit, at 12:11 PM. Additionally, Nursing Assistant, Staff C, acknowledged that there was no call light and revealed it has been at least one month since she has observed a call light in the resident's room. -Resident ID #4, who resides on the D Unit, at 1:40 PM. Additionally, Licensed Practical Nurse, Staff D, acknowledged that there was no call light and revealed that she was unsure how long the resident has been without a call light. Record review revealed price quotes to replace the call light system on the B Unit; one quote dated 1/6/2025 and another dating as far back as 4/1/2022. During a surveyor interview on 3/26/2025 at 1:16 PM with the Director of Maintenance, he revealed that that the call light system issue has been ongoing for months and needs replacement as the parts for the current call light system have been discontinued. He further revealed that the call lights continue to break one by one. Additionally, he revealed that the most recent quote from 1/6/2025 to replace the entire B Unit call light system had been approved by corporate, and the plan was to utilize the existing functional parts from the B Unit to repair the other units. However, he was unable to provide evidence of any documentation, contract, or project start date to indicate that the B Unit call light system replacement was underway. During a surveyor interview on 3/26/2025 at approximately 2:00 PM with the Administrator, he acknowledged that the call light issue has been ongoing and multiple residents are without call lights.

Dec 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**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 trea...

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**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, relative to following physician's orders for 1 of 1 resident reviewed relative to X-ray orders, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 11/27/2024, alleges that the resident fell, experienced increased pain, and impaired mobility. New orders were given by the provider for x-rays. The resident was subsequently sent out to the hospital and was diagnosed with two new fractures to his/her back. According to Mosby's 4th Edition, Fundamentals of Nursing page 314, which 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. Record review revealed that the resident was admitted to the facility in May of 2023 with diagnoses including, but not limited to, dementia, unsteadiness on his/her feet, and a history of falls. Record review of a progress note dated 11/23/2024 at 4:23 PM, authored by the on-call provider, revealed the resident had a fall and was found on the floor of his/her room. Initially s/he denied pain and later had complaints of lower back pain. Record review revealed a physician's order dated 11/23/2024 at 6:07 PM, for a stat (immediate) x-ray of the lumbar spine (lower back) and thoracic spine (region of the back between the neck and abdomen) two views (frontal and lateral), for back pain post fall. During a surveyor interview on 11/29/2024 at 2:13 PM, with Registered Nurse (RN), Staff A, she indicated she was assigned as the resident's nurse on 11/23/2024 during the 3:00 PM to 11:00 PM shift and indicated the resident stated s/he was having pain. Additionally, she indicated the x-ray technician arrived during her shift to perform the x-rays, as ordered. Record review of a mobile x-ray Radiology Interpretation report dated 11/23/2024 revealed only a lumbar x-ray single view (frontal view) was obtained. Further review revealed the second view (lateral view) of the lumbar spine was not obtained. The report failed to indicate information about the lateral view of the lumbar spine or the thoracic spine. During the surveyor interview with Staff A, she revealed that she read the Radiology Interpretation Report to the provider indicating that the x-ray was negative. When the surveyor questioned Staff A if she reported that the lateral view of the lumbar spine and the two views of the thoracic spine were not obtained, she stated I read them the impression report. During a surveyor interview on 12/2/2024 at 9:46 AM with the contracted Nurse Practioner, she indicated that the facility reported to the on-call provider on 11/24/2024 at 6:42 AM that the x-rays were obtained as ordered and were negative. Record review of a RN Acute/Reassessment note dated 11/25/2024 authored by contracted provider, Registered Nurse (RN), Case Manager, revealed in part, the resident was in his/her room sitting on the edge of the chair when asked to move up and back s/he complained of lower back pain and was yelling out oh lordy! S/he was taking deep breaths and exhaling in pain upon movement. S/he yelled out in pain when his/her lower lumbar area was mildly touched. Further the resident yelled out when attempts were made to move his/her left leg. Lastly, a pain assessment was completed indicating s/he was experiencing 10 out of 10 pain (severe pain) to his/her lower lumbar area and left leg and was unable to bear weight on his/her left leg. This RN called the provider, and an order was given to send the resident to the hospital for additional x-rays to be obtained, as the facility's elevator was down and additional x-rays could not be obtained. Record review of a hospital document titled emergency room to Hospital Admission report revealed the resident was admitted to the hospital on [DATE] status post fall. Additional review revealed a CT scan was obtained that resulted in the resident being diagnosed with new mild compression fractures (small breaks in the vertebrae of the spine) to his/her L4 (lumbar vertebrae 2 and 4) and T9 (thoracic vertebrae 9). During a surveyor interview with the contracted provider, RN, Case Manager, on 12/2/2024 at 9:00 AM she was unable to recall if the facility communicated to her that all of the x-rays that were ordered were not obtained. During a surveyor interview on 12/2/2024 at 10:15 AM with the Assistant Director of Nursing Services (ADNS), she was unable to provide evidence that the two views of the resident's lumbar and thoracic spine were obtained as ordered on 11/23/2024. Record review of a statement dated 11/29/2024 authored by the Radiological Technologist provided to the surveyor on 12/3/2024, one day after exiting the facility, which was not made available during the investigation, revealed that he was unable to obtain all of the x-rays as ordered.

Oct 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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 r...

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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 relative to physician's orders for 1 of 1 resident reviewed who was a new admission, Resident ID #1. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing page 314, which states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review revealed the resident was admitted to the facility in October of 2024 with diagnoses including, but not limited to, urinary tract infection (UTI) and dementia. Review of the hospital Continuity of Care- Post-Acute Facility document dated 10/9/2024, revealed an order for cephalexin (Keflex-an antibiotic) 500 milligrams (mg) twice a day for 2 days with instructions to contact the provider to ask if this medication should be continued. Review of a nursing admission note dated 10/9/2024 revealed the orders were reviewed with the on-call provider and a new order was obtained for Keflex 500 mg by mouth twice a day for 2 days. Review of the on-call provider's physician's orders dated 10/9/2024 revealed an order for Keflex 500 mg by mouth twice a day for 2 days. Review of the October 2024 Medication Administration Record failed to reveal the Keflex was transcribed or administered to the resident as ordered. During a surveyor interview on 10/23/2024 at approximately 1:00 PM with Licensed Practical Nurse, Staff A, she acknowledged that the resident did not received the antibiotic as ordered. During a surveyor interview on 10/23/2024 at 2:27 PM with Nurse Practitioner, Staff B, she indicated that if an on-call provider gives an order, she would expect that the order would be completed. During a surveyor interview on 10/23/2024 at 2:42 PM and at approximately 3:20 PM with the Director of Nursing Services, she acknowledged that the physician's order for Keflex had not been transcribed or administered as ordered. Additionally, she indicated that she would expect physician's orders to be followed.

Sept 2024 2 deficiencies 2 IJ

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Free from Abuse/Neglect (Tag F0600)

Someone could have died · This affected 1 resident

**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 keep a resi...

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**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 keep a resident free from neglect for 1 of 1 resident reviewed who attempted suicide, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 9/9/2024 alleges that Resident ID #1 tried to commit suicide on 9/7/2024. S/he had a belt around his/her neck and the family was not informed. Review of a facility policy titled, Suicide Attempt or Threats last revised in November of 2019 states in part, In the event a resident/patient attempts or is threatening suicide: Take all allegations seriously. Ensure the resident's/patient's immediate safety. Place the resident on 1:1 [constant supervision]. The charge nurse will notify the supervisor and attending physician. The supervisor or charge nurse will notify nursing administration. A staff member will be assigned to stay with the resident/patient on a one-to-one basis until the resident/patient is seen by psychiatry or sent to the Emergency Department. The staff member must be in close proximity to the resident/patient. Do not leave the resident/patient alone . Record review revealed that the resident was admitted to the facility in June of 2024 with diagnoses including, but not limited to, vascular dementia (dementia caused by a series of strokes that restricts blood flow to the brain) with agitation, depression, insomnia, and chronic post-traumatic stress disorder (PTSD). Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 12 out of 15 indicating, moderate cognitive impairment. Review of a progress note dated 9/7/2024 at 7:39 AM states in part, resident had a sleepless night .Resident was found later with belt tied to [his/her] neck, it took three of us to take it from [him/her]. During a surveyor interview on 9/10/2024 at approximately 9:00 AM with the Day Nursing Supervisor, Staff A, she revealed she was aware of the resident's suicide attempt that was made during the early morning hours of 9/7/2024. She revealed that the resident was on frequent checks on 9/7/2024, but not on one-to-one supervision. Additionally, she revealed that the resident's family member called the unit on 9/7/2024 at approximately 10:00 -10:30 AM, after the family member had spoken to the resident. The resident told the family member that s/he tried hanging him/herself overnight. The family member was questioning what the resident had just told them and called the facility to confirm. The family member spoke with Staff A, who confirmed what occurred overnight to the caller and told them that the facility wanted to send the resident out for a psychiatric evaluation. The caller then requested that the facility wait to send the resident out because they were on their way. Staff A further indicated that she checked the room for safety and when asked what the room check entailed, she revealed that she checked the room for sharp objects. During a surveyor interview on 9/10/2024 at 10:36 AM with the Night RN/Nursing Supervisor, Staff D, she revealed that the resident's room is directly across from the nurse's desk and that on the evening of 9/6/2024 into 9/7/2024, the resident was awake, in and out of his/her room, and very restless. Staff D indicated that between 2:00 AM and 3:00 AM, the resident came out of his/her room with a belt wrapped around his/her neck. Staff D indicated that she immediately approached the resident and called for help as she tried removing the belt from around the resident's neck. She revealed that it took three staff members to get the resident to release the belt from his/her neck. Additionally, she revealed that following the incident, the resident was placed on frequent safety checks and not on one-to-one supervision as stated in the facility's Suicide Attempts or Threats policy. Staff D indicated that she did not notify the resident's physician, the Director of Nursing (DON), or the resident's family. Furthermore, she acknowledged that she did not send the resident to the Emergency Department for a psychiatric evaluation following his/her suicide attempt. During a surveyor interview on 9/10/2024 at approximately 9:15 AM with Nursing Assistant (NA), Staff B, she revealed that on 9/7/2024 between 2:00 AM and 3:00 AM, she heard the nurse calling out that Resident ID #1 had a belt around his/her neck and that help was needed. Staff B indicated that it took three staff members (including herself) to talk the resident into releasing the belt and handing it to them. Additionally, Staff B revealed that she took the belt and placed it back in one of the resident's drawers where other belts were located. Staff B indicated she kept the resident safe the remainder of the shift by checking his/her room for sharp objects like scissors and razors and that the resident was checked on a lot. Staff B indicated the resident was not provided with one-to-one supervision. During a surveyor interview with Licensed Practical Nurse, Staff C, on 9/10/2024 at 10:50 AM, she revealed that the resident attempted to hang him/herself on the 11:00 PM to 7:00 AM shift on 9/7/2024 and was placed on frequent checks but was not on one-to-one supervision. Record review failed to reveal evidence that, per their facility policy, the resident was placed on one-to-one supervision, that the charge notified the physician and/or nursing administration, that a staff member was assigned to stay with the resident on a one-to-one basis until s/he was sent to the emergency room, and that the responsible party/family was notified. During a surveyor interview with the resident's family member on 9/11/2024 at approximately 9:30 AM, she revealed that she arrived at the facility at approximately 12:30 PM on 9/7/2024 and that she observed the resident crossing the parking lot without his/her walker. The resident was alone without a staff member present and greeted her at the car. Additionally, she revealed the resident was wearing a belt after having attempted to hang him/herself with a belt earlier that morning. During a surveyor interview on 9/11/2024 at approximately 1:00 PM with Staff E, Social Worker, she revealed that she saw the resident on 9/7/2024 when she arrived at work on 9/7/2024 between 10:00 -11:00 AM. Staff E revealed that the resident was outside alone, unattended by a staff member. She immediately went up to the resident's unit to notify the nurse, Staff C, who then sent a restorative aid outside to get him/her. Additionally, she indicated that she called the DON to report her findings of the resident being outside alone, indicating that the facility was not aware of the resident's whereabouts after s/he had attempted suicide earlier that morning. During a surveyor observation of the resident's room on 9/11/2024 at approximately 12:45 PM, the following was identified, resident's closet and dresser contained several pairs of shorts/pants and jackets with removable string ties. The resident's call light was attached to the resident's bed side rail and a phone with a long phone cord was observed on the resident's bedside table. Review of the facility's surveillance footage of 9/7/2024, in the presence of the Administrator, DON, and Assistant Director of Nursing (ADON), revealed the following occurrences: - 2:48 AM to 2:57 AM- The resident was observed ambulating in and out his/her room multiple times. S/he was also observed to sit in a chair for a few moments but then would get up. - 2:58 AM- The resident came out of his/her room with a belt wrapped around his/her neck and proceeds to sit in a chair outside of his/her room, visible from the nurse's station. Staff D approaches the resident and attempts to remove the belt. - 2:59 AM- Two NAs arrived to help the nurse remove the belt from the resident's neck. The NAs and Staff D were then observed walking the resident back into his/her room. - 3:00 AM to 7:00 AM- Revealed staff intermittently would enter and exit the resident's room. - 10:40 AM- Revealed the resident exiting the facility unattended and then goes out of view. - 11:15 AM - The Resident was observed walking back into the facility with the restorative aid. - 12:28 PM- The Resident was observed exiting the facility a second time unattended with his/her walker, crossing the parking lot and approached a parked car. The resident and his/her family member, who was in the parked car, then made their way to and sat at a picnic table until 1:44 PM. They were then observed entering the facility together. The resident was observed wearing a belt. - 2:20 PM- The Resident was observed being brought out of the facility to an ambulance. During a follow-up surveyor interview on 9/12/2024 at approximately 10:45 AM with Staff C, after the surveyor had viewed the surveillance footage, she acknowledged that the first time the resident was observed outside at approximately 10:40 AM, she realized the resident was missing and asked a restorative aid to search for him/her. She revealed that the second time the resident was observed outside at approximately 12:28 PM, she was not aware of his/her whereabouts. During a surveyor interview with the DON on 9/10/2024 at 9:45 AM, she revealed that she was not made aware of the events that occurred with Resident ID #1 on 9/7/2024 until approximately 10:00-10:30 AM, 7 hours after the incident had occurred. She indicated that she directed the staff to perform frequent checks until they sent the resident out to the hospital for a psychiatric evaluation. Furthermore, she revealed that she was initially unaware of the facility's Suicide Attempt or Threats policy and unaware of the unsafe items that remained in the resident's room, prior to him/her being sent to the hospital. Additionally, the DON acknowledged that the facility failed to place the resident on one-to-one supervision, notify the physician and/or nursing administration, assign a staff member to stay with the resident on a one-to-one basis until s/he was sent to the emergency room, and notify the responsible party/family of the incident. The facility failed to keep the resident free from neglect as evidenced by: - the failure to follow their own Suicide Attempt or Threats policy by not placing the resident on one-to-one supervision until s/he was sent to the hospital, notifying the physician and/or nursing administration, and notifying the responsible party/family of the incident. - the failure of staff members caring for the resident to identify that the cords, belts and ties in the resident's room were potential hazards and were left accessible to a resident who had just had a belt around his/her neck. - the failure to monitor the resident's whereabouts after making a suicide attempt, as s/he was observed outside of the facility unsupervised twice on the same day of the incident. These failures had the potential to place the resident at risk for more than minimal harm, death, or impairment. Cross reference F689

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected 1 resident

**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 ...

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**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 adequate supervision for 1 of 1 resident reviewed who attempted suicide, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 9/9/2024 alleges that Resident ID #1 tried to commit suicide on 9/7/2024. S/he had a belt around his/her neck and the family was not informed. Review of a facility policy titled, Suicide Attempt or Threats last revised in November of 2019 states in part, In the event a resident/patient attempts or is threatening suicide: Take all allegations seriously. Ensure the resident's/patient's immediate safety. Place the resident on 1:1 [constant supervision]. The charge nurse will notify the supervisor and attending physician. The supervisor or charge nurse will notify nursing administration. A staff member will be assigned to stay with the resident/patient on a one-to-one basis until the resident/patient is seen by psychiatry or sent to the Emergency Department. The staff member must be in close proximity to the resident/patient. Do not leave the resident/patient alone . Record review revealed that the resident was originally admitted to the facility in June of 2024 with diagnoses including but not limited to; chronic post-traumatic stress disorder, vascular dementia with agitation, major depressive disorder, insomnia and depression. Review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 12 out of 15, indicating that s/he has moderate cognitive impairment. Review of a care plan dated 6/26/2024 revealed the resident has a history of major depression and post-traumatic stress disorder (PTSD). Interventions include but are not limited to, provide emotional support as needed, encourage verbalization, and psychiatric consult or follow up as needed. Review of a progress note dated 9/7/2024 at 7:39 AM states in part, resident had a sleepless night .Resident was found later with belt tied to [his/her] neck, it took three of us to take it from [him/her]. During a surveyor interview on 9/10/2024 at approximately 9:00 AM with the Day Nursing Supervisor, Staff A, she revealed that she was aware of the resident's suicide attempt that was made during the early morning hours of 9/7/2024. She revealed that the resident was on frequent checks on 9/7/2024, but not on one-to-one supervision. Record review failed to reveal evidence that Resident ID #1 was placed on one-to-one supervision per the facility's policy or frequent checks, as indicated by Staff A. During a surveyor interview on 9/10/2024 at 10:36 AM with the Night RN/Nursing Supervisor, Staff D, she revealed that the resident's room is directly across from the nurse's desk and that on the night of 9/6/2024 into 9/7/2024, the resident was awake, in and out of his/her room, and very restless. Staff D indicated that between 2:00 AM and 3:00 AM, the resident came out of his/her room with a belt wrapped around his/her neck. Staff D indicated that she immediately approached the resident and called out for help as she tried removing the belt from around the resident's neck. She revealed that it took three staff members to get the resident to release the belt from his/her neck. Additionally, she revealed that following the incident, she did not place the resident on one-to-one supervision and instead placed him/her on frequent safety checks. Record review failed to reveal evidence that Resident ID #1 was placed on one-to-one supervision per the facility's policy or frequent checks, as indicated by Staff D. During a surveyor interview on 9/10/2024 at approximately 9:15 AM with Nursing Assistant (NA), Staff B, she revealed that on 9/7/2024 between 2:00 AM and 3:00 AM, she heard the nurse calling out that Resident ID #1 had a belt around his/her neck and that help was needed. Staff B indicated that it took three staff members (including herself) to talk the resident into releasing the belt and handing it to them. Additionally, Staff B revealed that she took the belt and placed it back in the resident's drawer where other belts were located. Staff B indicated she kept the resident safe the remainder of the shift by checking his/her room for sharp objects like scissors and razors and that the resident was checked on a lot. Staff B indicated the resident was not provided with one-to-one supervision. Record review failed to reveal evidence that Resident ID #1 was placed on one-to-one supervision per the facility's policy or checked on a lot, as indicated by Staff B. During a surveyor interview with Licensed Practical Nurse, Staff C, on 9/10/2024 at 10:50 AM, she revealed that the resident attempted to hang him/herself on the 11:00 PM to 7:00 AM shift on 9/7/2024 and was placed on frequent checks but was not on one-to-one supervision. Record review failed to reveal evidence that Resident ID #1 was placed on one-to-one supervision per the facility's policy or was placed on frequent checks, as indicated by Staff C. Record review failed to reveal evidence that, per the facility policy, the resident was placed on one-to-one supervision, the charge notified the physician and/or nursing administration, a staff member was assigned to stay with the resident on a one-to-one basis until s/he was sent to the emergency room, and that the responsible party/family was notified. During a surveyor interview with the resident's family member on 9/11/2024 at approximately 9:30 AM she revealed that she arrived at the facility at approximately 12:30 PM on 9/7/2024 and that she observed the resident crossing the parking lot without his/her walker. The resident was alone without a staff member present and greeted her at the car. Additionally, she revealed the resident was wearing a belt after attempting to hang him/herself with a belt earlier that morning. During a surveyor interview on 9/11/2024 at approximately 1:00 PM with Staff E, Social Worker, she revealed that she saw the resident on 9/7/2024 when she arrived at work on 9/7/2024 between 10:00 -11:00 AM. Staff E revealed that the resident was outside and unattended by a staff member. She immediately went up to the resident's unit to notify the nurse, Staff C, who then sent a restorative aid outside to return the resident into the facility. Additionally, she indicated that she called the DON to report her findings of the resident being outside alone, indicating that the facility was not aware of the resident's whereabouts after s/he had attempted suicide earlier that day. A surveyor observation of the resident's room on 9/11/2024 at approximately 12:45 PM revealed the resident's drawers and closet contained several pairs of shorts/pants and jackets with removable string ties. The resident's call light was attached to the resident's bed side rail and a phone with a long phone cord was observed on the resident's bedside table. Review of the facility's surveillance footage of 9/7/2024, in the presence of the Administrator, DON, and Assistant Director of Nursing (ADON), revealed the following occurrences: - 2:48 AM to 2:57 AM- The resident was observed ambulating in and out his/her room multiple times. S/he was also observed to sit in a chair for a few moments but then would get up. - 2:58 AM- The resident came out of his/her room with a belt wrapped around his/her neck and proceeds to sit at a chair outside of his/her room which was visible from the nurse's station. Staff D approached the resident and attempts to remove the belt. - 2:59 AM- Two NAs arrived to help the nurse to remove the belt from the resident's neck. The NAs and Staff D were then observed walking the resident back into his/her room. - 3:00 AM to 7:00 AM- Revealed staff intermittently enter and exit the resident's room. - 10:40 AM- Revealed the resident exiting the facility unattended and is out of line of sight of facility staff. Indicating, s/he was not receiving any supervision at that time. - 11:15 AM - The Resident was observed walking back into the facility with the restorative aid. - 12:28 PM- The Resident was observed exiting the facility a second time unattended with his/her walker, crossing the parking lot and approached a parked car. Indicating, s/he was not receiving any supervision for a second time. Further review revealed, the resident and his/her family member, who was in the parked car, made their way to and sat at a picnic table until 1:44 PM. They were then observed entering the facility together. The resident was observed wearing a belt. - 2:20 PM- The Resident was observed being brought out of the facility to an ambulance. During a follow-up surveyor interview on 9/12/2024 at approximately 10:45 AM with Staff C, after the surveyor had viewed the surveillance footage, Staff C acknowledged that the first time the resident was observed outside at approximately 10:40 AM she realized the resident was missing from the unit and asked a restorative aid to search for him/her. She revealed that the second time the resident was observed outside at approximately 12:28 PM, she was not aware of his/her whereabouts, indicating that the resident was not receiving any type of supervision both times s/he was able to leave the unit s/he resided on and the facility. During a surveyor interview with the DON on 9/10/2024 at 9:45 AM she revealed that she was not made aware of the events that occurred with Resident ID #1 on 9/7/2024 until approximately 10:00-10:30 AM, 7 hours after the incident had occurred. She indicated that she directed the staff to perform frequent checks until they sent the resident out to the hospital for a psychiatric evaluation. Furthermore, she revealed that she was initially unaware of the facility's Suicide Attempt or Threats policy and was unaware of the unsafe items that remained in the resident's room, prior to him/her being sent out to the hospital. Additionally, the DON acknowledged that the facility failed to place the resident on one-to-one supervision or assigning a staff member to stay with him/her on a one-to-one basis until s/he was sent to the emergency room, following his/her suicide attempt. Furthermore, the DON revealed that there was no documentation available to demonstrate that the facility had placed the resident on frequent checks for his/her safety. The facility's failures to ensure the resident received adequate supervision following an elopement attempt is evidenced by: - the failure to follow their own Suicide Attempt or Threats policy and not placing the resident on one-to-one supervision or assigning a staff member to stay with the resident on a one-to-one basis until s/he was sent to the emergency room. - the failure to supervise the resident after s/he tried to hang him/herself, as s/he was left unsupervised in his/her room where multiple ligature risks were accessible to him/her. - the failure to monitor his/her whereabouts after making a suicide attempt, as s/he was observed being outside of the facility unsupervised twice that same day. These failures had the potential to place the resident at risk for more than minimal harm, death, or impairment. Cross reference F600

Jul 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards o...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 1 of 1 resident reviewed, who has an actual pressure injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence), Resident ID #1. Findings are as follows: Record review of a community reported complaint received by the Rhode Island Department of Health on 6/27/2024 alleges that Resident ID #1 was found to have concerns with the status of his/her left lateral lower leg wound while being evaluated in the Emergency Department of an acute care hospital. Record review revealed the resident was re-admitted to the facility in June of 2024 with diagnoses including, but not limited to, sepsis, pressure injuries to the left lateral lower leg, left buttocks, right great toe, osteomyelitis (bone infection) and muscle wasting. Record review of the facility's contracted Wound Physician's progress note dated 6/11/2024 revealed a recommendation for a daily treatment for the resident's left lateral lower leg unstageable (full-thickness skin and tissue loss that is either partially or fully covered by slough-nonviable tissue with varying color that may adhere to the wound bed or dead tissue adhered to the wound bed) pressure wound. Record review of the physician's orders failed to reveal evidence that the wound physician's recommendations were acted upon from 6/12/2024 until it was brought to the facility's attention on 7/1/2024 by the surveyor, indicating the resident's left lower leg pressure wound did not have a treatment in place for 19 days. Record review of the facility's contracted Wound Physician's progress note dated 6/18/2024 revealed two new deep tissue injuries (purple or maroon area of discolored intact skin due to damage of underlying soft tissue) were identified to the resident's right great toe and left buttocks. Further review of the progress note revealed treatment recommendations to apply skin prep to both areas. Record review of the physician's orders failed to reveal evidence that a treatment order was implemented to the resident's right great toe or to the left buttock pressure wounds from 6/19/2024 until it was brought to the facility's attention on 7/1/2024 by the surveyor, indicating the resident's right great toe and left buttock wounds did not have a treatment order in place for 12 days. During a surveyor interview on 7/2/2024 at 10:08 AM with the resident's physician, he revealed that any wound recommendations made by the facility's contracted Wound Physician are followed for the residents' wound treatments. During a surveyor interview on 7/1/2024 at 2:44 PM with the Wound Nurse, she revealed that she completes wound assessments weekly with the Wound Physician and the recommendations that the Wound Physician makes, she enters them into the system as orders. Additionally, she was unable to explain why the wound treatments recommended on 6/11/2024 and 6/18/2024 were not implemented. During a surveyor interview on 7/1/2024 at 9:25 AM and at 2:15 PM with the Director of Nursing Services, she acknowledged there were no treatment orders for the resident's left lateral lower leg, right great toe, and left buttocks wounds until they were brought to the facility's attention by the surveyor.

Jun 2024 10 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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 #45. Findings are as ...

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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 #45. Findings are as follows: According to State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities, last revised 2/2023, .Abuse is the willful infliction of injury .with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Resident to Resident Abuse of Any Type A resident to resident altercation should be reviewed as a potential situation of abuse .Also, when investigating an allegation of abuse between residents, the surveyor should not automatically assume that abuse did not occur, especially in cases where either or both residents have a cognitive impairment or mental disorder. Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. In determining whether F 600-Free from Abuse and Neglect should be cited in these situations, it is important to remember that abuse includes the term 'willful'. The word 'willful' means that the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. An example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach .The facility may provide evidence that it completed a resident assessment and provided care planning interventions to address a resident's distressed behaviors such as physical, sexual or verbal aggression. However, based on the presence of resident to resident altercations, if the facility did not evaluate the effectiveness of the interventions and staff did not provide immediate interventions to assure the safety of residents, then the facility did not provide sufficient protection to prevent resident to resident abuse. For example, redirection alone is not a sufficiently protective response to a resident who will not be deterred from targeting other residents for abuse once he/she has been redirected . Record review of a facility incident report to the Rhode Island Department of Health on 6/11/2024, stated that the alleged perpetrator, Resident ID #81, was found over Resident ID #45 biting his/her cheek. Record review revealed that Resident ID #45, the alleged victim, was admitted to the facility in May of 2023 with diagnoses including, but not limited to, dementia without behavioral disturbances and anxiety. Review of the Minimum Data Set (MDS) Assessment for Resident ID #45 dated 5/29/2024, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that the resident's cognition was intact. Record review of Resident ID #45's progress notes revealed a Social Service note dated 6/11/2024, authored by the Director of Social Services (DSS), Staff B, which revealed in part, .When, prompted about the incident. [Resident ID #45] reported .'my roommate got up, sat on my bed, and bit me on my face' .[s/he]showed the DSS the mark on [his/her] face . Record review revealed that Resident ID #81, the alleged perpetrator, was admitted to the facility in November of 2021 with diagnoses including, but not limited to, anxiety and major depression. Review of a Quarterly MDS for Resident ID #81 dated 4/28/2024, revealed a BIMS score of 11 out of 15, indicating that the resident's cognition was moderately impaired. Review of Resident ID #81's care plan dated 12/6/2021 revealed the resident exhibited behavioral problems including, but not limited to, swearing, agitation, and combativeness. Further review revealed an intervention to provide immediate safety for the residents and others. Record review of a progress note dated 6/11/2024 for Resident ID #81, reveals in part, Around 12:10 am, staffs [were heard] screaming and yelling. When writer arrived in the resident's room, resident [ID #81] was sitting on [his/her] roommate's bed slapping on [his/her] roommate's face [Resident ID #45], swearing at [him/her]. [Resident ID #45] kept saying [Resident ID #81] bit me on my face .When asked resident [ID #81] what happened [s/he] reply: I wanted the lights off and [s/he] yelled at me, I bit [his/her] face and I had enough of [him/her]. Record review of an investigation statement authored by Nursing Assistant (NA) Staff G, dated 6/11/2024, states in part, .the nurse came and when we both removed them from each other but [Resident ID #81] .was still trying to hit [Resident ID#45] .we then moved [Resident ID #45] .to another room . Record review of an investigation statement authored by Licensed Practical Nurse, Staff R, dated 6/11/2024, states in part, .When writer arrived there found [NA] removing [him/her] roommate [Resident ID #81] away from the resident [ID #45]. While we were trying to separate them [Resident ID #81] still tried to hit [Resident ID #45] . Record review for Resident ID #45 revealed a telehealth evaluation dated 6/11/2024 at 5:15 AM, authored by a doctor of osteopathic medicine, Staff A, revealed in part, .[Resident ID #45] post assaulted by roommate and was bitten on face per nurse around 1230am .Patient initially c/o [complaint of] pain but now has no pain .Exam findings per nurse and video observation .skin: right cheek, mod [moderately] pink redness, bite marks .start Moxifloxacin [antibiotic] 400 mg [milligrams] PO [by mouth] daily x 7 days RE: [related to] human bite injury . Right cheek bite injury: cleanse, pat dry and apply topical antibiotics daily x 7 days . Surveyor observation of Resident ID #45, on 6/26/2024 at 1:25 PM revealed a purple discoloration was noted on the upper area of Resident ID #45's right cheek. During a surveyor interview immediately following the above observation, the resident revealed that s/he remembers the incident and indicated that the perpetrator was his/her roommate. The resident indicated that the perpetrator attacked him/her while s/he was in bed. The resident further indicated that s/he had pain to his/her cheek for a week following the incident and that it was treated. Additionally, the resident indicated that s/he felt strongly that this attack was abuse. During a surveyor interview on 6/26/2024 at 3:34 PM with Director of Nursing Services, she acknowledged that Resident ID #45 was assaulted by his/her roommate and that s/he sustained a bite to his/her face. Additionally, she was unable to provide evidence that the facility kept Resident ID #45 free from abuse.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of practice relative to following physici...

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Based on record review and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of practice relative to following physicians orders for 2 of 4 residents reviewed relative to obtaining weekly weights, Resident ID #s 53 and 96. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, .The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients . 1. Record review revealed Resident ID #53 was re-admitted to the facility in May of 2024 with diagnoses including, but not limited to, dysphagia and severe protein calorie malnutrition. Record review revealed a physician's order dated 5/2/2024 with a start date of 5/6/2024 for weekly weights. Record review of the documented weights revealed the following: 5/7/2024 123.4 lbs. (pounds) 5/14/2024 not obtained 5/21/2024 not obtained 5/27/2024 123.3 lbs. 6/3/2024 not obtained Record review of the nursing progress note dated 5/14/2024 revealed the weight was unable to be obtained as ordered, without any further indication as to why. During a surveyor interview on 6/26/2024 at 3:46 PM with the Director of Nursing Services (DNS), she was unable to explain what was meant by the documentation that his/her weight was unable to be obtained. The DNS revealed she would expect that the nurse would indicate why the resident's weight was not obtained and an additional attempt would be made to obtain the resident's weight at a later time. Additionally, she was unable to provide evidence of the resident's weekly weights for the weeks of 5/14/2024, 5/21/2024 and 6/3/2024. 2. Record review revealed Resident ID #96 was re-admitted to the facility in May of 2024 with diagnoses including, but not limited to, weakness and diabetes mellitus. Record review revealed a physician's order dated 5/12/2024 with a start date of 5/13/2024 to obtain a weight on admission and weekly weights for 4 consecutive weeks post admission, then reassess. Record review of the documented weights revealed the following: 5/20/2024 111.4 lbs. 5/27/2024 106.4 lbs. 6/3/2024 104.8 lbs. 6/10/2024 not obtained 6/17/2024 not obtained 6/25/2024 109.2 lbs. During a surveyor interview on 6/26/2024 at 3:46 PM with the DNS, she was unable to provide evidence of the missing weekly weights for 6/10/2024 and 6/17/2024. Additionally, she indicated that she would have expected staff to have followed the physicians orders to obtain the weights.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**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 provide treatment and care in acco...

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**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 provide treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed with a history of a deep vein thrombosis (DVT), Resident ID # 36. Findings are as follows: According to Nursing Health Assessment: A clinical Judgement Approach 4th edition, 2023 published by Wolters Kluwer, it has been revealed that characteristics of a Deep Vein Thrombosis, (DVT) also known as a blood clot, include, but are not limited to, pain and swelling at the site. Review of the facility policy titled, Condition: Significant Change states in part, .Staff will communicate with the physician .regarding changes in condition to provide timely communication of resident/patient status change which is essential to quality care management . Record review revealed Resident ID #36 was readmitted to the facility in May of 2024 with a diagnosis including, but not limited to, acute embolism and thrombosis of deep veins of the right lower extremity. Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. During a surveyor interview on 6/24/2024 at 9:42 AM with Resident ID #36, s/he indicated that his/her left leg was red and warm. The resident further indicated that the nursing staff were aware and that s/he recently had a hematoma in his/her right leg, that is now an open wound. Record review revealed the following progress notes: 6/22/2024 at 10:19 PM- The resident stated that s/he was experiencing a new onset of increased pain to his/her left lower leg.history of DVT and hematoma that required surgical intervention. LLE [left lower extremity] noted with redness and edema .Patient reports 10/10 pain. Endorsed to oncoming nurse patient's symptoms and complaints. 6/23/2024 at 8:24 AM- Patient stated pain is excruciating/radiating and unbearable .medicated patient with prn [as needed] Percocet [pain medication]. Patient LLE noted with edema on outer L [left] side mild discoloration and warmth. Reported to MD with new orders for STAT [as soon as possible] Venous Doppler [ultrasound], Stat labs .and UA [urinalysis] to rule out sepsis . 6/23/2024 at 3:33 PM- .Awaiting .Venous Doppler .continues to endorse pain from LLE . Record review revealed a physician's order dated 6/23/2024 at 7:32 AM for a STAT venous doppler. Further review failed to reveal evidence that a provider was notified that the Venous Doppler had not been completed as ordered. Record review failed to reveal evidence that a provider was notified of the change in condition on 6/22/2024 until the next morning, on 6/23/2024. During a surveyor interview on 6/26/2024 at 10:55 AM with Licensed Practical Nurse (LPN) Staff C, she indicated that the venous doppler had not yet been completed as ordered at that time. She further indicated that the order had not been transcribed as STAT. Additionally, she could not provide evidence that a provider was notified on 6/22/2024 of the change in condition or that the venous doppler had not yet been completed as ordered. During a surveyor interview on 6/26/2024 at 11:18 AM with Nurse Practitioner, Staff D, she indicated that she was made aware of the resident's change in condition on 6/24/2024, however was unaware that the venous doppler had not been completed as ordered. She further indicated that she would have expected nursing to notify a provider that it had not been completed as ordered. Additionally, she indicated that due to the resident's history of a DVT, the resident needed to be sent to the hospital for an evaluation immediately. During a surveyor interview on 6/26/2024 at 12:57 PM with the Medical Director, he indicated that he would expect a STAT order to be completed the day it was ordered. He further indicated that he would expect a provider to be notified of a change in condition and if an order was not completed. Additionally, he indicated that the resident should be sent to the hospital for an evaluation if a STAT venous doppler could not be completed timely at the facility. During a surveyor interview on 6/26/2024 at 11:46 AM with the Director of Nursing Services, she acknowledged that the STAT venous doppler that was ordered on 6/23/2024 had not been completed as ordered or that the physician had been notified that it was not completed, until after the surveyor brought it to the facility's attention. She further indicated that the resident was being sent to the emergency department to obtain a venous doppler immediately. Additional record review revealed that, while at the emergency department, the resident was found to have a small complex fluid collection in the calf which is likely a hematoma or possibly a small abscess.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards o...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 1 of 3 residents reviewed for pressure ulcers (a localized injury to the skin or underlying tissue due to pressure), Resident ID #42. Findings are as follows: Record review revealed Resident ID #42 was admitted to the facility in January of 2023 with diagnoses including, but not limited to, Alzheimer's disease, and pressure ulcers to the coccyx (tail bone), and left heel. Record review revealed a physician's treatment order dated 6/14/2024 which states in part, .Skin prep periwound [area around the wound]. Apply medihoney f/b [follwed-by] calcium alginate [an absorbent dressing] and cover with foam dressing .Location: left heel every evening shift . Record review revealed a physician's treatment order dated 6/19/2024 which states .Pat dry. Apply medihoney and bordered foam dressing .Location: coccyx [every] evening shift . During a surveyor observation of the wounds on 6/26/2024 at 11:17 AM with Licensed Practical Nurse (LPN), Staff E, revealed the resident had two dressings dated 6/24/2024; one covering his/her coccyx, and one covering his/her left heel. Additional observation of the wound care revealed Staff E removed a soiled dressing from the coccyx, cleansed wound area with normal saline, and applied barrier cream to the wound rather than the medihoney as ordered. Staff E then exited the room and failed to cover the coccyx wound with the bordered foam dressing as ordered. During a surveyor interview on 6/26/2024 at 11:23 AM, with the Infection Preventionist, s/he revealed that the resident's wound treatments should be completed daily as ordered. Additionally, s/he would expect the wound dressings to be completed as ordered. During a surveyor interview on 6/26/2024 at 12:22 PM, with Staff E, she indicated that she was uncertain of the order prior to providing the wound care to Resident ID #42. Additionally, Staff E acknowledged the wound dressings she removed from the resident were dated 6/24/2024, indicating that the dressings had not been completed daily as ordered. During a surveyor interview on 6/26/2024 at 12:30 PM, with the Director of Nursing Services, she indicated that she would expect the physician's orders to be followed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis (a blood purifying treatment given when kidney function is not...

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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis (a blood purifying treatment given when kidney function is not optimum) receive such services consistent with professional standards of practice for 1 of 1 resident reviewed for dialysis, Resident ID #36. Findings are as follows: Review of the facility policy titled Hemodialysis states in part, .To provide comprehensive care to residents/patients .Communication between the facility and the hemodialysis center will occur using a communication book/sheet that consists of .Any change of condition from last hemodialysis treatment . Record review revealed Resident ID #36 was readmitted to the facility in May of 2024 with diagnoses including, but not limited to, acute kidney failure and chronic kidney disease, stage 4 (severe). Record review of a care plan last revised on 6/3/2024 revealed, the resident has a diagnosis of chronic kidney disease and started on dialysis. Further review revealed an intervention including, but not limited to, monitor lab work as ordered by the physician. Record review revealed the resident receives hemodialysis three times a week at a dialysis center. Record review revealed a physician's order dated 6/23/2024 for STAT (as soon possible) labs. Record review of the lab results dated 6/23/2024 revealed a critically low potassium level of 3.0 milliequivalents per liter (mEq/L; normal range 3.5-5.4 mEq/L). Record review revealed the physician was notified of the critically low potassium level on 6/23/2024. Further review revealed a physician's order dated 6/23/2024 for a STAT dose of potassium due to the critical level. Review of a Nurse Practitioner's (NP) note dated 6/24/2024 revealed, NP reviewed labs. Contact nephrology [a medical professional who specializes in kidney function] for hypokalemia [low potassium level] management ASAP [as soon as possible] given dialysis status. Review of the Hemodialysis Communication Sheet dated 6/25/2024 failed to reveal evidence that the resident's critical lab values and change of condition was communicated to the dialysis center or nephrology. Review of lab results dated 6/26/2024 revealed a potassium level of 3.3 mEq/L, indicating continued hypokalemia. During a surveyor interview on 6/26/2024 at 1:18 PM with Licensed Practical Nurse, Staff C, she indicated that the nursing staff are responsible for communicating with dialysis via the communication sheet. She further indicated that she completed the communication sheet dated 6/25/2024 and did not include the resident's potassium level because she was unaware of the resident's lab results or of the NP's progress note. Additionally, Staff C contacted the dialysis center at that time and was informed that nephrology had not been made aware of the resident's critically low potassium level until just prior to her call. During a surveyor interview on 6/26/2024 at 1:45 PM with the Director of Nursing Services, she could not provide evidence that the facility effectively communicated the resident's critically low potassium level to the dialysis center prior to the surveyor bringing it to the facility's attention.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to complete an annual performance review for every nurse aide (nursing assistant; NA), at least once every 1...

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Based on record review and staff interview, it has been determined that the facility failed to complete an annual performance review for every nurse aide (nursing assistant; NA), at least once every 12 months, for 4 of 7 NA personnel records reviewed, Staff F, G, H, I. Findings are as follows: Record review of the personnel files failed to reveal evidence that an annual performance evaluation was completed for the following NAs: -Staff F, Date of hire 11/18/2022 -Staff G, Date of hire 1/21/2020 -Staff H, Date of hire 1/30/2013 -Staff I, Date of hire 9/22/2020 During a surveyor interview with the Director of Nursing Services on 6/26/2024 at 10:45 AM, she was unable to provide evidence of a completed performance evaluation within the last 12 months for the above-mentioned employees.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to address pharmacy recommendations in a timely manner for 2 of 5 residents reviewed for unnecessary medicat...

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Based on record review and staff interview, it has been determined that the facility failed to address pharmacy recommendations in a timely manner for 2 of 5 residents reviewed for unnecessary medications. Resident ID #s 22 and 97. Findings are as follows: Record review of the facility policy titled, Drug Regimen Review-Monthly states in part, .The attending Physician or licensed designee shall respond to the Drug Regimen Review within 7-14 days or more promptly, whenever possible . 1a. Review of the 4/9/2024 pharmacy recommendations for Resident ID #22 revealed a recommendation to reduce the resident's Pravastatin (a medication used to treat high cholesterol) from 20 milligrams (mg) to 10 mg. Additionally, it revealed that the recommendation was not signed by the provider until 6/20/2024. In addition, the recommendation had not been implemented until it was brought to the facility's attention by the surveyor, indicating that it had been over 2 months since the recommendation was made. 1 b. Review of the 6/10/2024 pharmacy recommendations for Resident ID #22 revealed a recommendation to conduct a trial discontinuation of Risperdal (an antipsychotic medication) 0.25 mg. The recommendation was signed by the physician on 6/11/2024, however was not implemented. 2. Review of the 5/9/2024 pharmacy recommendation for Resident ID #97 revealed a recommendation to obtain a Valproic Acid (VPA; Valproic Acid is medication used to treat seizures and psychiatric conditions) serum (blood) level within two weeks and then every 6 months (blood levels of VPA must stay within a specific range for the drug to work effectively and to monitor for toxic levels). Further review revealed the recommendation was signed by the physician on 6/11/2024. Record review revealed the VPA level was not obtained until 6/26/2024, after it was brought to the facility's attention by the surveyor on 6/25/2024. Review of the lab report dated 6/26/2024 revealed a VPA level of 19.8 micrograms (MCG)/milliliters(ML). Further review revealed the therapeutic level is 50-125 MCG/ML indicating a subtherapeutic level. During a surveyor interview on 6/25/2024 at 5:08 PM with the Director of Nursing Services, she acknowledged that the pharmacy recommendations for Resident ID #s 22 and 97 had not been completed prior to the surveyor bringing it to the facility's attention. Additionally, she indicated that she would expect all pharmacy recommendations to be completed within 14 days per the facility's policy.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmissi...

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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections due to the facility's failure to utilize appropriate Enhanced Barrier Precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes), for 4 of 8 residents reviewed, Resident ID #s 84, 28, 42, and 163. Additionally, the facility failed to conduct appropriate infection control practices relative to the handling of soiled linen. Findings are as follows: Record review of the facility policy titled Enhanced Barrier Precautions Policy states in part, .implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms .MDROs are organisms that are resistant to all or most antibiotics .MRDOs may include, but are not limited to: Methicillin-resistant Staphylococcus aureus (MRSA) .ESBL [Extended Spectrum Beta Lactimase] .Enhanced Barrier Precautions require the use of gown and gloves for certain residents during specific high-contact resident care activities .bathing/showering, providing hygiene, dressing, transferring, linen changes, toileting, device care, and wound care .signage will be posted on the door or wall outside of the resident room indicating the need for enhanced barrier precautions .carts with appropriate [Personal Protective Equipment] PPE will be placed outside of the resident's room .enhanced barrier precautions will be continued while the .indwelling device is still active or in use . Review of the Centers for Disease Control and Prevention (CDC) guidance titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) updated on 7/12/2022 reveals in part, .Enhanced Barrier Precautions All residents with any of the following .Wounds .During high-contact resident care activities . Dressing, Bathing .Transferring .Providing hygiene .Changing briefs or assisting with toileting .Gloves and gown prior to the high-contact care activity . 1a. Record review revealed Resident ID #84 was admitted to the facility in May of 2024 with a diagnosis including, but not limited to, MRSA. Record review of a care plan dated 4/3/2024 revealed the resident had an increased susceptibility for infections related to right foot wounds. Further review revealed enhanced barrier precautions are in place as ordered, to reduce the risk of a transmittable infection. Record review of lab results dated 5/6/2024 revealed the resident's right heel wound tested positive for MRSA. During a surveyor observation on 6/25/2024 at 12:11 PM of the resident's wound care revealed the following: Licensed Practical Nurse (LPN), Staff C, entered the resident's room with wound care supplies including, but not limited to, a multipack gauze, a calcium alginate sheet (a sterile absorbent wound dressing), 2 pairs of scissors, wound cleanser spray bottle, and wide medical tape. Staff C touched the wound wash spray bottle multiple times with dirty gloves while cleansing the wound as well as grabbing more gauze from the multi-package of gauze. Additionally, she placed the sheet of calcium alginate up to the wound bed to measure the area and cut the sheet to size. She then cut a piece of tape from the roll to adhere the wound dressing to the resident. Staff C performed hand hygiene and removed the roll of tape, multi-package of gauze, scissors, wound wash, and the remainder of the sheet of calcium alginate out of the resident's room and placed the items on the treatment cart in the hallway. Staff C began placing the items back into the treatment cart when she was stopped by the surveyor. During a surveyor interview immediately following the above observations with Staff C, she indicated that she was going to place the wound care items back into the treatment cart to be used for again for other residents. Additionally, she acknowledged that the resident was on enhanced barrier precautions in place related to MRSA in his/her wound. During a surveyor interview on 6/25/2024 at 1:04 PM with the Director of Nursing Services (DNS), she indicated that the wound care supplies should not have been removed from the resident's room and that those supplies should not be used for any other residents. 1b. Record review revealed Resident ID #28 was admitted to the facility in May of 2024 with a diagnosis including, but not limited to, a history of Extended Spectrum Beta Lactamase (ESBL, a MDRO) infection in his/her urine. Record review revealed an order dated 5/24/2024 for Enhanced Barrier Precautions. Surveyor observations on 6/24/2024 and 6/25/2024 failed to reveal evidence of a precaution bin or the appropriate signage posted outside of the resident's room indicating the need for Enhanced Barrier Precautions. During surveyor observations on the following dates and times staff were observed without the proper personal protective equipment (PPE). -6/25/2024 at 9:14 AM- Nursing Assistant, Staff N, in the resident's room, touching the bed and pillows, without wearing a gown -6/25/2024 at 9:56 AM- Staff N entered the resident's room and assisted the resident off of the bed pan without wearing a gown During a surveyor interview on 6/25/2024 at 10:11 AM with Staff N, she indicated that she helped the resident with toileting without wearing a gown because she was unaware that the resident had an order for enhanced barrier precautions. Additionally, she indicated that she was unaware that the resident had a history of ESBL. During a surveyor interview and observation of Resident ID #28's room on 6/25/2024 at 10:14 AM, with Certified Medication Technician (CMT), Staff M, she acknowledged there was no sign indicating the resident required Enhanced Barrier Precautions or that precaution bins were placed outside of the resident's room. During a surveyor interview on 6/25/2024 at 10:16 AM with Licensed Practical Nurse, Staff C, after reviewing the resident's medical record, she indicated that the resident was positive for ESBL in his/her urine and should have enhanced barrier precautions in place. During a surveyor interview on 6/25/2024 at 10:22 AM with the Infection Preventionist, she revealed the resident is positive for an ESBL infection. She further revealed that enhanced barrier precautions signage and a precaution cart with the necessary PPE should be outside of the resident's door for staff to utilize when providing care. During a surveyor interview on 6/25/2024 at 10:28 AM with the DNS, she acknowledged that Resident ID #28 should have enhanced barrier precautions in place as ordered. 1c. Record review revealed Resident ID #42 was admitted to the facility in January of 2023 with a diagnosis including, but not limited to, Alzheimer's disease. Additionally, the record revealed the resident has pressure ulcers (a localized injury to the skin or underlying tissue due to pressure) to the coccyx (tail bone) and left heel. During surveyor observations from 6/24/2024 through 6/26/2024 revealed the resident had a sign and a bin next to the entrance door to the room for enhanced barrier precautions. During a surveyor observation on 6/26/2024 at 10:42 AM, NA, Staff Q, entered the resident's room with supplies to provide personal care and indicated to the surveyor that she was ready to begin without wearing a gown. The surveyor then asked Staff Q to review the appropriate PPE needed for the resident. During a surveyor interview with Staff Q, immediately following the above observation, she acknowledged that she should wear a gown and gloves prior to providing personal care to the resident. During a surveyor interview on 6/26/2024 at 4:19 PM with the DNS, she revealed that she would expect staff to wear a gown and gloves to provide care for a resident who requires enhanced barrier precautions. 1d. Record review revealed Resident ID #163 was admitted to the facility in June of 2024 with a diagnosis including, but not limited to, gastrostomy tube (a tube inserted into the stomach to provide nutrition). During surveyor observations on 6/24, 6/25, and 6/26/2024, failed to reveal evidence of a precaution bin or the appropriate signage posted outside of the resident's room indicating the need for enhanced barrier precautions. During a surveyor interview on 6/26/2024 at 3:08 PM with LPN, Staff O, she indicated that she was unaware if the resident should have enhanced barrier precautions in place. During a surveyor interview on 6/26/2024 at 3:39 PM with the DNS, she indicated that the resident has a gastrostomy tube and would expect enhanced barrier precautions to be in place. 2. Review of the CDC document titled, Guidelines for Environmental Infection Control in Health-Care Facilities last updated July 2019, states in part, .Collecting, Transporting, and Sorting Contaminated Textiles and Fabrics .Handling contaminated laundry with a minimum of agitation can help prevent the generation of potentially contaminated lint aerosols in patient-care areas .Contaminated textiles and fabrics are placed into bags or other appropriate containment in this location; these bags are then securely tied or otherwise closed to prevent leakage . During a surveyor observation on 6/26/2024 at 8:45 AM, NA, Staff P, was observed changing Resident ID #92's bed linens and placing the soiled linens on the floor. During a surveyor interview with Staff P, immediately following the above observation, he indicated that he was unaware that he should not place dirty linens on the floor. During an interview with Licensed Practical Nurse, Staff C, immediately following the above observation and interview with Staff P, she acknowledged that soiled items, including bed linens, should not be placed on the floor. During a surveyor interview with the Regional Director of Clinical Services on 6/26/2024 at 3:35 PM, she indicated that she would expect staff members to place soiled linens in a bag and prevent soiled items from touching the floor.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

**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 prepare, s...

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**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 prepare, store, and distribute food according to professional standards of food service safety, relative to the main kitchen and 3 of 4 nourishment areas observed. Findings are as follows: 1a. Review of the Rhode Island Food Code, 2018 Edition, section 4-601.11 states in part, (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch . During the initial tour of the main kitchen with the [NAME] Supervisor on 6/24/2024 at 8:45 AM, the following was observed: - One of three chef's knives with dried brown food matter on the blade - The blade of the countertop can opener was covered in a black, sticky residue During a surveyor interview with the [NAME] Supervisor immediately following the above observation, she acknowledged that the above items were dirty and needed to be cleaned. 1b. Review of the Rhode Island Food Code, 2018 Edition, section 3-501.17 states in part, .(B) .refrigerated, ready-to-eat time/temperature control for safety food .shall be clearly marked, at the time the original container is opened in a food establishment .and: (1) the day the original container is opened in the food establishment shall be counted as Day1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date . During a surveyor observation of the reach-in refrigerator in the main kitchen on 6/24/2024 at approximately 9:00 AM, the following was observed: - 12 four ounce (oz) plastic cups with what appeared to be applesauce, not labeled or dated - 18 four oz plastic cups with what appeared to be mixed fruit, not labeled or dated During a surveyor interview with the [NAME] Supervisor immediately following the above observation, she acknowledged that the above foods should be labeled and dated. 1c. Review of the Rhode Island Food Code, 2018 Edition, section 2-402.11 states in part, .Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens . During surveyor observations of Dietary Aide, Staff J, in the main kitchen on 6/24/2024 at 8:45 AM and 10:55 AM, he was handling food and equipment without a beard restraint. During a surveyor observation of Cook, Staff K, in the main kitchen on 6/24/2024 at 10:55 AM, he was at the stove preparing the lunch meal without wearing a beard restraint. During a surveyor interview with the [NAME] Supervisor immediately following the above observations, she acknowledged that Staff J and K should have been wearing beard coverings while working in the main kitchen. 2. Review of the Rhode Island Food Code, 2018 Edition, section 3-501.17 states in part, .(B) .refrigerated, ready-to-eat time/temperature control for safety food .shall be clearly marked, at the time the original container is opened in a food establishment .and: (1) the day the original container is opened in the food establishment shall be counted as Day1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date . Review of the Rhode Island Food Code, 2018 Edition, section 4-601.11 states in part, (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch . Record review of a facility policy titled, Use & Storage of Food Brought In By Family or Visitors, last revised November 2016 states in part, .All food items that are already prepared by the family or visitor brought in, must be labeled with content and date. The facility may refrigerate, label and date prepared items in the nourishment refrigerator. The prepared food must be consumed by the resident within 3 days. If not consumed within 3 days, food will be thrown away by facility staff . 2 a. During a surveyor observation of the A Unit nourishment area on 6/24/2024 at 11:15 AM, the following was observed: - Dried brown food debris was stuck to the top of the toaster - In the refrigerator, there were two 46 oz containers of honey thickened lemon flavored water, open and not dated. There was one 46 oz container of nectar thickened lemon flavored water, open, not dated, and missing the cap. Manufacturer's instructions indicate the product is to be used within 7 days after opening. During a surveyor interview with Licensed Practical Nurse (LPN), Staff L, immediately following the above observation, she acknowledged that the toaster was dirty and that the thickened beverages should have been dated when opened. 2 b. During a surveyor observation of the B Unit nourishment area on 6/24/2024 at approximately 11:20 AM, the following was observed in the refrigerator: - One 46 oz container of nectar thickened lemon flavored water, open and not dated. - A plastic store bought container with sliced strawberries and blueberries, not labeled or dated. - A brown paper bag containing unidentified food items, labeled [resident name] 11A, without a date. - A cheeseburger covered in plastic wrap, not labeled or dated. - Four burger patties covered in plastic wrap, not labeled or dated. - An unidentified food item wrapped in foil, marked C, not labeled or dated. - 2 paper bowls taped together with unidentified food items inside, labeled 11A, without a date. - Another small brown paper bag containing unidentified food items, labeled 11A, without a date. - 1 vanilla and 2 strawberry-flavored four oz [NAME] Readycare shakes with a use-by date of 6/10/2024. During a surveyor interview with LPN, Staff C, immediately following the above observations, she acknowledged that the above food and beverage items were not labeled or dated correctly and that the shakes should have been discarded, as they were past their use-by date. 2 c. During a surveyor observation of the C Unit nourishment area on 6/24/2024 at 11:40 AM, the following was observed in the refrigerator: - One 46 oz container of nectar thickened lemon flavored water, opened and not dated. - A rectangular glass storage container with orange colored food inside, labeled 6/24. - A black, round takeout container with rice, vegetables and meat, labeled 6/24. - A plastic, quart sized container of chicken noodle soup labeled 18B 6/16/24. - 2 strawberry flavored, four oz [NAME] Readycare shakes with a use-by date of 6/14/2024. During a surveyor interview with Nursing Assistant, Staff M, immediately following the above observation, she acknowledged that the above food and beverage items were not labeled or dated correctly and that the shakes should have been discarded, as they were past their use-by date. During a surveyor interview with the Registered Dietitian and [NAME] Supervisor on 6/24/2024 at 12:15 PM, they indicated they would expect all food and beverages to be dated when opened, expired foods to be discarded, food equipment to be clean, all employees to wear appropriate hair coverings, and that nourishment area refrigerators are maintained in accordance with the facility's policy.

MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0577 (Tag F0577)

Minor procedural issue · This affected most or all residents

Based on record review and staff, and resident interview, it has been determined that the facility failed to post the results of the most recent survey in a readily accessible area for the residents, ...

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Based on record review and staff, and resident interview, it has been determined that the facility failed to post the results of the most recent survey in a readily accessible area for the residents, staff, and public. Findings are as follows: During the resident council task on 6/24/2024 at 12:37 PM, the residents stated that they were aware of the State Inspection results but stated concerns about having to access to it. During a surveyor observation on 6/25/2024 at 10:00 AM, a sign near the front desk states Department of Health Survey Book Available Upon Request in Receptionist office. Review of the facility's survey results binder revealed that the last entry was from a survey conducted in December of 2023, and did not include the most recent survey results from April of 2024. During a surveyor interview with the Regional Director of Clinical Services on 6/25/2024 at 4:38 PM, she revealed that the binder was not updated to include the most recent surveys for the year of 2024. She further indicated that the survey results binder should be updated and placed in a readily accessible location.

Apr 2024 1 deficiency 1 IJ

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected 1 resident

**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 receives adequat...

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**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 receives adequate supervision to prevent accidents for 1 of 4 residents reviewed who successfully eloped from the facility and for whom interventions and assessments were not implemented, Resident ID #4. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 4/18/2024 alleges that Resident ID #4 had eloped from the facility successfully twice. Review of the facility policy titled Elopement states in part, .Elopement is defined as the ability of a resident who is not capable of protecting himself or herself from harm to successfully leave the facility unsupervised and unnoticed and who may enter into harm's way . - The licensed nurse will conduct an elopement screen on admission, re-admission, annually, upon change of condition. Residents identified at risk for elopement will have their photo maintained in a confidential manner at the main entrance to the facility. - A care plan will be developed and implemented for any resident at risk of elopement . Review of a facility policy titled Discharge Against Medical Advice (AMA) states in part, .Procedure (MA/RI) . - An order for AMA will be written. - Documentation will be made in the clinical record with details of the discharge to include persons notified, statement of reason for discharge, if known, the date and time of discharge. - The resident/patient and or legal representative will sign the AMA form and it will be placed in the clinical record. - Appropriate agencies will be notified by the Social Worker or member of center to provide additional services to the resident, if necessary, in the community . Record review revealed the resident was admitted to the facility in September 2023 with diagnoses including, but not limited to, schizoaffective disorder, adjustment disorder, traumatic brain injury, developmental delay, mild intellectual disability, and type 2 diabetes mellitus. Record review of a document titled Psychiatric Evaluation and Consult dated 2/1/2024, revealed the resident has, .schizoaffective disorder, bipolar type .[S/he] demonstrated AVH [auditory verbal hallucinations] and paranoia at today's visit but did not appear as agitated as last visit. I will continue to monitor. Mild-intellectual disability may complicate medication teaching . 1a. Record review of a progress notes revealed on 2/2/2024, the resident went to a behavioral health appointment in the community. Additional review of this progress note revealed that s/he was accompanied by facility staff, Nursing Assistant (NA), Staff A, and that the resident ran out of the provider's office. Staff A and the staff at the provider's office pursued the resident but were unable to reach him/her as s/he fled the building. The note further revealed that the facility assumed the resident left AMA, the resident's family was contacted and it was indicated that if the resident were to be found, s/he would need to go to the Emergency Department to be medically cleared before s/he could return to the facility, as the resident has a history of substance abuse. Review of a statement authored by Staff A on 2/2/2024 states, I went in to the appointment with the resident, while we were in the waiting room, [s/he] started to get aggravated saying [s/he] 'was going to leave and if the cops came looking for [him/her], [s/he] would kick their a**,' [s/he] was pacing back and forth. The doctor came and took us into her office, the resident wasn't answering her questions she was asking [him/her]. [S/he] just kept saying 'I don't want to talk about it' She was trying to find out what was bothering [him/her], then [s/he] stood up and took off out the door. The doctor followed [him/her] trying to redirect [him/her], but [s/he] had left the building. Cops were called and I gave my description of [him/her]. During a surveyor interview with Staff A on 4/19/2024 at 10:50 AM, she indicated that she usually accompanies residents that are not alert and oriented to their appointments. Additionally she indicated that she was asked to accompany Resident ID #4 to his/her behavioral health appointment in the community on the morning of 2/2/2024. She further revealed that the doctor's office called the local police department to locate the resident as they were unable to find him/her after s/he ran off. During a surveyor interview with Registered Nurse (RN), Staff B, on 4/19/2024 at approximately 2:15 PM, she revealed that on 2/2/2024 at approximately 4:00 PM, she was looking out the window and happened to see the resident outside of the facility with Emergency Medical Services (EMS). Staff B indicated that this was the first time that the resident was seen at the facility after running out of the doctor's office that morning. Staff B acknowledged it was unclear how the resident made it back to the facility. EMS informed her that the resident had called 911, and they were taking him/her to the hospital. She further revealed that the resident informed her that s/he was made aware by his/her sister, that in order for him/her to be able to return to the facility, s/he needed to go to the hospital for medical clearance first. Record review of a document titled RI EMS Patient Care Report dated 2/2/2024 at 4:03 PM indicated the resident was agitated standing outside the nursing home. A nurse reported the resident is eloping from nursing home. The resident is at the nursing home due to his/her inability to self-medicate properly, and that s/he has a history of schizoaffective disorder, traumatic brain injury, bipolar disorder, and diabetes. Record review of a document titled Continuity of Care Consultation and Referral Form dated 2/2/2024, revealed the resident eloped from [provider's office] after refusing to participate in [his/her] appointment with psychiatrist. The local Police have been informed and will attempt to locate the client and bring [him/her] to the ED [Emergency Department] for further evaluation. During a surveyor interview with the Director of Nursing Services (DNS), in the presence of Staff B, on 4/19/2024 at approximately 2:20 PM, she unable to explain how the resident returned to the facility on 2/2/2024, s/he fled from the provider's office, approximately 6.7 miles away from the facility. Additionally, she was unable to explain where the resident had been for approximately 6 hours from the time after s/he fled from the provider's office unsupervised and presented him/herself back to the facility. During a surveyor interview with Staff A on 4/22/2024 at 11:30 AM, she revealed she was unaware if the resident had a cell phone or wallet on him/her at the time s/he fled from the provider's office on 2/2/2024. During a surveyor interview with the Regional Director of Nursing (RDNS), on 4/19/2024 at approximately 11:10 AM, in the presence of the DNS, she revealed that on 2/2/2024, the resident left the provider's office of his/her own will and that s/he is alert and oriented, therefore it was her interpretation that the resident had left AMA from the facility and had not in fact eloped. Additionally, she was also unable to provide evidence of a completed AMA discharge from the facility nor was she able to provide evidence that an Elopement & Wandering Risk Assessment had been completed for the resident following the above-mentioned incident when s/he was left unsupervised in the community. Record review failed to reveal evidence that the facility analyzed the events of 2/2/2024 or discharged the resident AMA on 2/2/2024. As the resident's record did not contain an order for an AMA discharge, documentation was not found in the clinical record with details of such a discharge to include persons notified, statement of the reason for discharge was not documented, the date and time of discharge was not documented, the resident or his/her legal representative had not signed an AMA form, an AMA form was not found in his/her clinical record, appropriate agencies were not notified by the Social Worker or a member of the facility to provide additional services to the resident, per the facility's AMA policy. Record review of a document dated 3/18/2024, titled Elopement & Wandering revealed the resident was not at risk for elopement, despite the above-mentioned incident that took place on 2/2/2024 with police involvement. Record review of the resident's care plan failed to reveal evidence that s/he was assessed for elopement risks or that interventions were put in place as a result of the incident on 2/2/2024. 1b. Record review of a progress note dated 4/6/2024 revealed the resident had called 911 and walked by the nurse stating, I'm leaving and I'm not coming back. The nurse then watched the resident leave the premises and then the nurse informed her supervisor. Record review of a document titled Orchard View Manor Security Log dated 4/6/2024 through 4/7/2024, revealed that on 4/6/2024, at 7:50 PM, the resident walked out of the building and was heading towards [NAME] farms on Wampanoag Trail, a [nurse] and [security guard] tried to get [him/her] to come back but [s/he] refused. [Nurse] called the police and they took [him/her] to the hospital. Record review of a document titled, RI EMS Patient Care Report dated 4/6/2024 revealed an emergent call was received at 7:52 PM, for Psychiatric Problem/Suicide Attempt/Suicide threats with primary symptoms of altered mental status. The report revealed the resident was found standing with the local police, approximately 0.5 miles away from the facility and was transported to the hospital for further evaluation. The report further reveals the resident has a history of schizophrenia, and past medical history including, but not limited to, schizoaffective disorder, altered mental status, acute kidney failure, traumatic brain injury as well as alcohol abuse. Further review revealed s/he presented with a blood pressure of 161 systolic and 79 diastolic, (a normal range for an adult is 120-129 systolic and less than 80 diastolic) and s/he had with pulse rate of 124 beats per minutes (normal range is 60 to 100 beats per minute). The report also indicates that s/he was in distress and was noted to be verbally confused upon assessment. Further record review revealed an additional RI EMS Patient Care Report dated 4/6/2024 at 10:19 PM which revealed that EMS was dispatched to the hospital to transport the resident back to the facility as the resident required ambulance transportation for medical supervision for safety of self due to cognitive impairment after being brought to the hospital's emergency department for eloping from the facility with reported behavioral changes. The resident was secured to a stretcher with 5 safety belts in place. Record review failed to reveal evidence that the facility analyzed the events of 4/6/2024 or that the resident was assessed for elopement behaviors relative to this incident. During a surveyor interview with the DNS on 4/19/2024 at approximately 2:20 PM, she revealed she was not aware of the resident's successful elopement on 4/6/2024 until 4/8/2024. She revealed that the facility staff should have followed the facility's policy and should have conducted an elopement assessment. 1c. Record review of a facility reported incident submitted to the Rhode Island Department of Health on 4/7/2024, revealed the resident had eloped from the facility following a verbal altercation with another resident which escalated to a physical incident. The police were notified, and the resident was transported to the hospital for further evaluation. Record review of the resident's progress notes revealed that on 4/7/2024 at 3:44 PM, the resident has had two incidents of elopements within 24 hr. The first one was on 4/6 with no known triggering factors. Second incident happened 4/7 after the resident got into a verbal altercation with another resident that turned physical . Record review of a document titled RI EMS Patient Care Report dated 4/7/2024 at 3:19 PM states in part, .were dispatched for a mental health evaluation .found patient in parking lot with police . Record review revealed that the resident had not returned to the facility as of 4/23/2024. Record review revealed that the resident's care plan was updated sometime on 4/7/2024 which indicates the .Resident is at risk to to try to leave nursing facility Attempting to leave the facility, Expressed desires to go home., Pacing, roaming 4/6 and 4/7 attempted to leave facility . With interventions that include, If resident is seen at an exit encourage to come with staff. During a surveyor interview with the resident's physician on 4/23/2024 at approximately 11:37 AM, he revealed that he was unable to recall if he was made aware of the incidents regarding Resident ID #4 on 2/2/2024 when s/he eloped from the behavioral health center and returned unsupervised to the facility several hours later. Additionally, he was unable to recall if he was made aware of the successful elopements from the facility on 4/6/2024 and 4/7/2024. He indicated that the Administrator informed him of these incidents the morning of 4/23/2024. He indicated it was his expectation that the facility would have conducted elopement behavior assessments. The facility's failure to follow their own policy relative to elopements and AMA discharges, to properly assess and identify the resident as an elopement risk and provide interventions for added safety measures for a resident who has diagnoses of schizoaffective disorder, adjustment disorder, traumatic brain injury, developmental delay, and a mild intellectual disability placed him/her at risk for serious injury, harm, impairment, or death.

Feb 2024 2 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Quality of Care (Tag F0684)

A resident was harmed · This affected 1 resident

Based on record review and staff interview if has been determined that the facility failed to promptly identify and intervene during an acute change in a resident's condition, related to a mental stat...

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Based on record review and staff interview if has been determined that the facility failed to promptly identify and intervene during an acute change in a resident's condition, related to a mental status change and a fall, for 1 of 1 resident reviewed for a change in condition, Resident ID #1. Findings are as follows: Review of a facility policy titled Condition: Significant Change states in part, .staff will communicate with the physician, resident/patient, and family regarding changes in condition to provide timely communication of resident/patient status change which is essential to quality care management . Review of a facility policy titled, Hypoglycemia- Clinical Management Of states in part, Hypoglycemia is defined as finger stick or serum glucose less than 60 mg./dl [milligram per deciliter] .if symptoms of a low blood sugar (hypoglycemia) are present, immediate intervention is necessary . Symptoms of hypoglycemia include, but are not limited to, lethargy, confusion, and a change in mental status. Record review revealed Resident ID #1 was admitted to the facility in February of 2024 with diagnoses including, but not limited to, diabetes mellitus type 2, heart failure, chronic obstructive pulmonary disease (COPD), and a history of falling. Record review failed to reveal a care plan in place to include instructions needed to provide effective and person-centered care. Record review of the admission progress note revealed the resident was alert and oriented times 4 (person, place, time, and situation), verbally responsive, and able to make needs known. Record review revealed on 2/6/2024 the resident fell while independently ambulating to the bathroom, resulting in a laceration to his/her head and significant bleeding from the wound. Further review revealed the resident was sent to the hospital for an evaluation following the fall; staples were placed to close the laceration to his/her head. Record review reveled the resident sustained a subsequent unwitnessed fall on 2/14/2024 at approximately 2:00 AM. Record review of a nursing progress note dated 2/14/2024 at 8:43 AM revealed the resident was found on the floor by his/her wheelchair and was alert and oriented times 2. Further review revealed the resident sustained an injury to his/her toe with minimal bleeding noted. The resident was transferred from the floor back to bed. Additional review failed to reveal that the resident's blood sugar was obtained at the time of the fall. Record review of a nursing progress note dated 2/14/2024 at 11:26 AM states in part, Resident is S/p [status post] fall from 2 AM 2/14/24, resident was noted to be lethargic, weak, unable to answer questions correctly, and appears confused, not responding to verbal stimuli, resident is alert and oriented at baseline .resident b/s [blood sugar] was noted to be 57 mg/dl .1 dose of glucagon [emergency medication to increase blood sugar] IM [intramuscularly] administered and b/s rechecked noted 88 mg/dl after 30 minutes, resident started being responsive to verbal stimuli but appears lethargic, fatigued and confused .DNS/MD [Director of Nursing Services/ Medical Doctor] made aware . Further review revealed the resident was sent to the hospital for an evaluation via 911. Record review of the hospital documentation dated 2/15/2024 revealed the resident's glucose on admission was 56, indicating s/he was hypoglycemic. During a surveyor interview on 2/15/2024 at 1:27 PM with Registered Nurse, Staff B, she revealed that she assessed the resident after she was alerted by a Nursing Assistant that the resident was found on the floor in his/her room. She further revealed that upon assessment the resident was able to recall his/her name and that s/he was at a facility however, s/he was unaware of the date and stated that s/he had been sitting there on the floor all day. Additionally, Staff B indicated that she was unaware of the resident's mental status change at that time and she didn't think to obtain his/her blood sugar. Furthermore, she revealed that she did not contact the physician at the time of the fall and indicated several hours later, after 7:00 AM, she left a message for the on call physician. During a surveyor interview on 2/15/2024 at 12:46 PM with Registered Nurse, Staff C, she indicated that she entered the resident's room at approximately 9:00 AM to obtain his/her scheduled vital signs and blood sugar, as ordered. She indicated that when she entered the resident's room, s/he was not responding. Staff C further indicated that the resident's blood sugar was 57 mg/dl at that time. Additionally, Staff C indicated that she administered glucagon IM, as ordered, for hypoglycemia and obtained an order from the physician to send the resident to the hospital for further evaluation. During a surveyor interview on 2/15/2024 at 12:23 PM with the DNS, she acknowledged that the resident had a change in condition at the time of the fall as evidenced by his/her mental status change and could not provide evidence that the resident's blood sugar was obtained at that time. Additionally, she indicated that she would expect a change in mental status to be identified and that the physician be notified timely.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected most or all residents

Based on record review and staff interview, it has been determined the facility failed to develop and implement a baseline care plan for each resident within 48 hours of a resident's admission, that i...

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Based on record review and staff interview, it has been determined the facility failed to develop and implement a baseline care plan for each resident within 48 hours of a resident's admission, that includes the instructions needed to provide effective and person-centered care for 3 of 3 residents reviewed. Resident ID #s 1, 2, and 3. Findings are as follows: According to the State Operations Manual, Appendix PP- Guidance to Surveyors for Long Term Care Facilities, revised on 2/3/2023, §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must- (i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- (A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable . 1. Record review revealed Resident ID #1 was admitted to the facility in February of 2024 with diagnoses including, but not limited to, diabetes mellitus type 2, heart failure, chronic obstructive pulmonary disease (COPD), and a history of falling. Record review failed to reveal evidence that a baseline care plan had been completed. During a surveyor interview on 2/15/2024 at 11:04 AM with the MDS (Minimum Data Set) Coordinator, she indicated that she develops the residents' comprehensive care plans; however, the nurses on the units are expected to complete the residents' baseline care plans upon admission. Additionally, she acknowledged that Resident ID #1's baseline care plan had not been completed. 2. Record review revealed Resident ID #2 was admitted to the facility in February of 2024 with diagnoses including, but not limited to, COPD, a fracture of the left pubis (part of the pelvis), and a history of falling. Record review failed to reveal evidence that a baseline care plan had been completed. During a surveyor interview on 2/15/2024 at 11:39 AM with the MDS Coordinator, she indicated that she would expect the baseline care plan to be completed on admission. Additionally, she acknowledged that Resident ID #2's baseline care plan had not been completed. 3. Record review revealed Resident ID #3 was admitted to the facility in January of 2024 with diagnoses including, but not limited to, hemiplegia (paralysis on one side of the body), aphasia (inability to understand or express speech), traumatic brain injury, and seizures. Record review failed to reveal evidence that a baseline care plan had been completed. During a surveyor interview on 2/15/2024 at 11:46 AM with Licensed Practical Nurse, Staff A she indicated that the baseline care plans should be completed by the nurse on admission. Additionally, she acknowledged Resident ID # 3's baseline care plan had not been completed. During a surveyor interview on 2/15/2024 at 12:23 PM with the Director of Nursing Services, she was unable to provide evidence that a baseline care plan was developed for the above-mentioned residents within 48 hours of admission, to include instructions needed to provide effective and person-centered care.

Jan 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observations, record review, staff and resident interview, it has been determined the facility failed to treat...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observations, record review, staff and resident interview, it has been determined the facility failed to treat each resident with respect and dignity, and is cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life relative to assistance with eating during meals for 1 of 1 hospice resident reviewed, Resident ID #5. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 12/27/2023 alleges in part, .patients .called nursing staff for [his/her] roommate who had woken up hungry. Apparently, the roommate was sleeping when dinner was served, and staff didn't save [his/her] dinner or wake [him/her] to eat . Record review revealed the resident was admitted to the facility in August of 2023 with diagnoses including, but not limited to, cerebral infarction (stroke) and mild cognitive impairment. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident requires extensive assistance of one staff member for eating. Surveyor observations on 1/3/2024 revealed the following: - 10:12 AM: Resident ID #5 lying in bed with his/her breakfast tray on the bedside table. The bedside table was positioned against the wall, away from his/her bed, and out of his/her reach. The breakfast tray consisted of a full cup of white liquid, a full cup of clear liquid, an unopened cereal package, 2 slices of french toast, 2 bacon strips, and home fries - all of which appeared untouched. - 10:15 AM to 11:26 AM: Multiple staff members entering and exiting Resident ID #5's room several times. The resident had his/her room cleaned, a nurse completed his/her treatments, and the resident was transferred from the bed to a wheelchair. Additionally, no staff member was observed to have attempted to assist the resident with eating during this time. - 11:21 AM: The lunch cart arrived on the unit. - 11:29 AM: Nursing Assistant (NA), Staff A, exited the resident's room with the resident's untouched breakfast tray and placed it in the dietary cart. - 11:35 AM: Resident ID #5's lunch tray was brought into his/her room and placed on the bedside table. The bedside table was positioned against the wall, away from his/her bed, and out of his/her reach - 11:44 AM: Staff A was observed by the surveyor from the hall standing over the Resident ID #5 and assisting the resident with eating while s/he was in his/her wheelchair. The surveyor entered the room and noted Staff A was now seated away from the resident and was on his cell phone. During a simultaneous surveyor interview following the above observation on 1/3/2024 at approximately 11:45 AM with Staff A, he was unable to explain why he was on his cell phone or why he was standing while assisting the resident with eating his/her lunch. Additionally, when questioned about the resident's breakfast meal, he indicated that the resident ate poorly for breakfast only consuming a few spoonfuls of oatmeal (which was not observed on the resident's breakfast tray). He revealed that if a resident refuses to eat or eats poorly (consuming less than 26% of the meal), he will tell the nurse or notify the kitchen for an alternate meal. He further revealed that he did not inform the nurse, but instead contacted the kitchen and requested scrambled eggs and home fries for the resident around 10:30 AM. Additionally, he indicated that the resident ate better once the alternate meal arrived, however he was unable to recall what time the alternate meal arrived on the unit and was unable to identify who he spoke with in the kitchen. During a surveyor interview on 1/3/2024 at 12:51 PM with the entire kitchen staff in the presence of the chef, they indicated that they did not receive a call from a staff member requesting an alternate meal for Resident ID #5, nor did any kitchen staff prepare or deliver scrambled eggs and home fries to any of the units after the breakfast carts were distributed. During a surveyor interview on 1/3/2024 at 1:09 PM with the resident's roommate (who is cognitively intact), s/he indicated that s/he ate breakfast in his/her room and did not observe Resident ID #5 to have eaten breakfast. During a surveyor interview on 1/3/2024 at 1:20 PM with Dietary Aide, Staff B, he indicated that he was one of the staff members responsible in assembling all the resident's meal trays and ensuring that the meal ticket and tray contents match. He further indicated that Resident ID #5 wouldn't have received oatmeal on his/her breakfast tray that morning based on the main breakfast item served that day, which he indicated was 2 slices of french toast and 2 bacon strips. During a surveyor interview with the Director of Nursing Services on 1/3/2024 at approximately 1:40 PM, she revealed that breakfast is served between 7:30 AM - 8:30 AM. She acknowledged that she would expect the resident to have eaten his/her breakfast or that staff would notify the nurse if the resident ate poorly. She further revealed that she would expect staff to assist the resident with eating in a dignified manner, including remaining seated next to the resident for the duration of the meal and remain off their cell phone. She was unable to provide evidence that the resident was treated with respect and dignity, and cared for in a manner that promotes maintenance or enhancement of his/her quality of life. Refer to F 842.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to maintain ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and practices for 1 of 1 hospice resident reviewed for the breakfast meal, Resident ID #5. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 12/27/2023 alleges in part, .patients .called nursing staff for [his/her] roommate who had woken up hungry. Apparently, the roommate was sleeping when dinner was served, and staff didn't save [his/her] dinner or wake [him/her] to eat . Record review revealed the resident was admitted to the facility in August of 2023 with diagnoses including, but not limited to, cerebral infarction (stroke) and mild cognitive impairment. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident requires extensive assistance of one staff member for eating. Surveyor observations on 1/3/2024 of the resident in his/her room revealed the following: - 10:12 AM: Lying in bed with his/her breakfast tray on the bedside table that appeared untouched. The breakfast tray consisted of a full cup of white liquid, a full cup of clear liquid, an unopened generic Cheerios package, 2 slices of french toast, 2 bacon strips, and home fries - all of which appeared untouched. - 11:29 AM: Nursing Assistant (NA), Staff A, exited the room with the resident's untouched breakfast tray and placed it in the dietary cart. During a surveyor interview on 1/3/2024 at approximately 11:45 AM with Staff A, when questioned about the resident's breakfast meal, he indicated he assisted the resident with eating breakfast, and that the resident ate poorly, only consuming a few spoonfuls of oatmeal (which was not observed on the resident's breakfast tray). He revealed that he contacted the kitchen and requested scrambled eggs and home fries for the resident around 10:30 AM. Review of the resident's breakfast meal intake for 1/3/2024 was documented that the resident consumed 51-75% of his/her meal. Additionally, it was time stamped at 9:37 AM. During a follow up surveyor interview on 1/3/2024 at approximately 1:00 PM with Staff A, he was unable to explain why he documented that on 1/3/2024 at 9:37 AM, the resident consumed 51-75% of his/her breakfast when he indicated to the surveyor that the resident ate poorly. During a surveyor interview with the Director of Nursing Services on 1/3/2024 at approximately 1:40 PM, she indicated that she would expect that staff would document the resident's meal intake accurately. She was unable to provide evidence that the facility maintained accurate medical records in accordance with professional standards and practices. Refer to F 550

Dec 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**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 a resident's environm...

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**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 a resident's environment remains as free of accident hazards as possible for 1 of 3 residents reviewed for falls, Resident ID #1. Findings are as follows: Record review reveals the resident was admitted to the facility in September of 2021 with diagnoses to include, but not limited to, acute and chronic respiratory failure with hypoxia (a low level of oxygen in the blood) and hypercapnia (a higher than normal level of carbon dioxide in the blood), chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, and morbid obesity. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15 indicating that the resident is cognitively intact. It further revealed that the resident requires 2+ person assist for bed mobility, including turning side to side, and positioning while in bed. Record review of the resident's care plan, initiated on 9/23/2021 revealed a focus area, .requires assistance with Bathing, Dressing, Grooming, Requires extensive assist Interventions include but are not limited to, .extensive to dependent for ADLs [activities of daily living] of 1-2 staff . Review of a document titled, Occupational Therapy .Evaluation & Plan of Treatment dated 2/12/2023 revealed in part, .Bed mobility .Total Dependence . Impressions .Max A [maximum assistance] to reposition in bed .[Patient] is functioning at baseline, therefore skilled OT [Occupational Therapy] is not indicated at this time . Review of a document titled, Rehab- Screen dated 10/11/2023 revealed in part, BED MOBILITY- moving in bed with or without assistive device, going to/from lying position, side to side .Existing Deficit No Change in Function . Record review of a progress note dated 12/2/2023 revealed that, upon entry to the room, the nurse found the resident on the floor with his/her right arm on the bed and left arm on the oxygen concentrator. The resident was alert and oriented with range of motion to all extremities and did not hit his/her head. The resident complained of a of level 2-3 out of 10 for pain to the right outer ankle and had a small abrasion to the left elbow. In order to get the resident back into bed, a Hoyer lift (mechanical lift) and the assistance of 4 staff members was required. It further revealed that the CNA and the resident both stated that the CNA was on the left side of the bed when assisting the resident to roll towards the right side of the bed. When the resident was turned, the air in the air mattress shifted to the left side and causing the right side of the mattress to deflate, as a result, the patient rolled off of the bed on to the floor. During a telephone interview on 12/5/2023 at approximately 12:00 PM, with Nursing Assistant. Staff A, she revealed that she was the CNA assisting the resident on 12/2/2023 when s/he fell out of bed. She further revealed that she was providing care alone, turning the resident away from her in the bed, and the resident fell off the side of the bed that s/he was turning towards. During a surveyor interview on 12/5/2023 at 1:25 PM with the MDS coordinator, she revealed that the resident required extensive assist of two people for bed mobility as documented in the MDS dated [DATE]. She further revealed she would have expected that this would have been documented more clearly in the resident's care plan. She acknowledged that the care plan stated extensive to dependent for ADLs of 1 -2 staff . During a surveyor interview on 12/5/2023 at approximately 2:30 PM with Physical Therapist, Staff B, she revealed that the resident was coded as total dependence for bed mobility on the OT visit dated 2/12/2023, which indicates s/he would require the assistance of two people. She further revealed subsequent quarterly rehab screenings indicated that the resident's bed mobility was documented as Existing Deficit No Change in Function . She acknowledged that this indicates the resident would still require the assistance from two staff members for bed mobility. During a surveyor interview on 12/5/2023 at approximately 3:15 PM with the Director of Nursing Services, she revealed that she would expect two staff to assist with the turning and repositioning of the resident in bed.

Nov 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff and resident interviews, it has been determined that the facility failed...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff and resident interviews, it has been determined that the facility failed to ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good personal hygiene for 1 of 3 residents reviewed for showers, Resident ID #2. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 11/5/2023 alleged, that the resident .wasn't being washed well and certain areas were even rarely being washed . Review of the facility's policy titled SHOWERS states in part, Resident .will receive a shower .as desired . Record review revealed the resident was re-admitted to the facility in August of 2023 with diagnoses including, but not limited to, morbid obesity and osteoarthritis (a degenerative joint disease). Record review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 15 out of 15, indicating the resident's cognition was intact. Further review revealed the resident is totally dependent on staff for bathing, including showers. Record review of the resident's care plan last revised 9/26/2023, revealed .has ADL [Activities of Daily Living] Deficit .Goal .[the resident] will be clean . Record review of the progress notes revealed the resident was noted to be crying and complaining of not being cleaned correctly on 10/1/2023 and 10/11/2023. Further record review failed to reveal evidence any interventions were put into place following the resident's concerns. Record review failed to reveal the resident received a shower for 4 weeks, from 9/28/2023 until 10/28/2023. Record review of a Non-Pressure Wound Evaluation dated 10/27/2023 revealed the resident's groin was excoriated (remove of part of the surface of the skin). Further review revealed the date of origin was documented as 10/22/2023. Record review revealed a physician's order dated 10/27/2023 to apply house antifungal cream to groin after commode use and ADL care. Further review revealed this treatment was still in place during this survey on 11/9/2023. During a surveyor interview on 11/9/2023 at approximately 11:40 AM with the resident, s/he indicated that s/he would like a shower however s/he has not received showers regularly. The resident further indicated that the staff do not use soap when completing his/her bed baths, and that s/he has a rash. Surveyor observations during the above interview revealed the resident's hair appeared unclean. Record review of a QAPI (Quality Assurance and Performance Improvement) plan with the project initiation date of 12/9/2022 revealed a problem that residents were not being showered weekly and there was no appropriate documentation. Further review revealed weekly audits will be implemented to ensure all residents receive showers and if they refuse, appropriate documentation would be performed. Additionally, the Director of Nursing was labeled as the person responsible for the QAPI. Record review failed to reveal evidence that the weekly shower audits were completed since July 2023, as outlined in the QAPI plan. During a surveyor interview on 11/9/2023 at approximately 11:50 AM with Licensed Practical Nurse (LPN) Staff A, she indicated that each resident is scheduled to be showered weekly. Additionally, she acknowledged that there was no documentation that the resident had received a shower from 9/28/2023 until 10/28/2023. During a surveyor interview on 11/9/2023 at 12:06 PM with the Director of Nursing Services, she indicated that the residents should receive a shower once a week and showers should be documented when completed. Additionally, she indicated that the facility had previously put a QAPI plan in place identifying a problem with residents receiving weekly showers. However, she discontinued auditing weekly showers in July of 2023 because she didn't feel it was necessary anymore. Furthermore, she was unable to provide evidence that the resident received or refused a shower from 9/28/2023 until 10/28/2023.

Jul 2023 14 deficiencies 4 IJ

CRITICAL (J)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0658 (Tag F0658)

Someone could have died · This affected 1 resident

Based on surveyor observation, 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 a...

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Based on surveyor observation, 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 a nurse transcribing an order for NPO (nothing by mouth) without a physician's order and discontinuing a medication without physician authorization for 1 of 1 resident reviewed, Resident ID #99. Additionally, the facility failed to follow a physician's order for 1 of 3 residents reviewed for blood sugar monitoring, and for 1 of 2 residents observed for wound care, Resident ID #11. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 states: The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. 1. Record review revealed Resident ID #99 was admitted to the facility in May of 2023 with diagnoses of, but not limited to, malignant neoplasm of the brain (brain cancer) and mild protein calorie malnutrition. Record review revealed a physician order dated 5/13/2023 states in part, Regular diet, Regular Consistency texture, Thin (Regular) Liquids consistency. Record review revealed a care plan dated 5/25/2023 revealed the resident has no dietary restrictions. It further revealed that Staff will provide House regular diet .Staff will provide favorite foods and beverages on request as comfort measure. S/he eats a variety of foods, except fish & shellfish and cereal. S/he enjoys most other foods. [Resident ID #99] is open to suggestions for snacks and beverages between meals, and will request as desired. S/he enjoys most types of snacks . Record review revealed an order was transcribed on 6/22/2023 which states, NPO entered by Licensed Practical Nurse (LPN), Staff D. Additional record review revealed the resident did not consume food or fluids for 6 days after the order for NPO was initiated. This order was entered into the medical record by Staff D without authorization by a physician. During a surveyor interview on 6/27/2023 at 8:14 AM with Registered Nurse (RN), Staff B, she revealed that the resident was NPO because the resident was receiving hospice services. During a surveyor interview on 6/27/2023 at 11:15 AM with Hospice RN, Staff C, she revealed that hospice would not have recommended a resident to be NPO. She further revealed that hospice would encourage a resident to eat. During a surveyor interview on 6/27/2023 at 1:47 PM with the resident's physician, he revealed that he would not make a resident on hospice services NPO, and further revealed he would expect the staff to encourage a resident on hospice to eat and drink for comfort. Further record review revealed the resident had a physician's order for Dexamethasone (a medication to provide temporary symptomatic relief of symptoms related to increased pressure and edema secondary to brain cancer) twice a day. This order was also discontinued on 6/22/2023 by Staff D without authorization by a physician. During a surveyor interview on 6/28/2023 at 2:00 PM with Staff D, she acknowledged that she discontinued the Dexamethasone and entered the order for Resident ID #99 to be NPO. She revealed that she did not obtain a physician's order for NPO or to discontinue the Dexamethasone. During a subsequent surveyor interview on 6/28/2023 at 8:38 AM with Staff B, she revealed that Resident ID #99 had expired on 6/28/2023. During a surveyor interview with the Director of Nursing Services (DNS) on 6/28/2023 at 9:34 AM, she revealed that Staff D entered the order for Resident ID #99 to be NPO and discontinued the Dexamethasone without obtaining a physician's order. This failure resulted in Resident ID #99 not eating or drinking for 6 days leading up to his/her death. The system failures of the facility staff entering and following physician orders for its residents, without prior authorization from a physician, unequivocally placed Resident ID #99 at risk for serious harm, impairment or death as food, hydration and significant medications were withheld from him/her for the 6 days that led up to his/her death. 2a. Record review revealed Resident ID #11 was admitted to the facility in January of 2014 with a diagnosis including, but not limited to, type 1 diabetes mellitus. Record review revealed a physician order dated 5/8/2023 which states in part, If blood sugar is over 400 administer standing order and sliding scale, recheck in 2 hours, if still over 400 call VA [Veteran Affairs] . Further record review revealed that the resident received scheduled insulin three times a day along with a sliding scale insulin based on the resident's blood sugar, if needed. Record review of the June 2023 Medication Administration Record revealed that the resident's blood sugar exceeded 400 on the following dates and times, which would require that staff recheck the resident's blood sugar in 2 hours as per the physician order: 6/05/2023 - 11:30 AM, blood sugar 417 6/13/2023 - 11:30 AM, blood sugar 413 6/14/2023 - 11:30 AM, blood sugar 449 6/15/2023 - 11:30 AM, blood sugar 425 6/19/2023 - 07:30 AM, blood sugar 450 Record review failed to reveal evidence that the resident's blood sugar on the above dates and times were rechecked per the physician order. During a surveyor interview on 6/29/2023 at 9:51 AM with the DNS, she acknowledged that the above mentioned blood sugar levels were above 400 and would expect the resident's blood sugar to be rechecked per the physician's order and documented in the medical record. 2b. Record review revealed Resident ID #11 was admitted to the facility in January of 2014 with a diagnosis including, but not limited to, type 1 diabetes mellitus. Record review of a facility policy titled Clean Dressing Technique states in part, .Check physicians order for current and correct treatment . Record review revealed the resident has a wound to the bottom of his/her foot (plantar aspect). Record review revealed the following physician orders relative to wound care: - 5/2/2023: Plantar wound - apply a saline soaked Hydrofera blue (improves growth or formation of wound while wicking drainage and debris from the wound bed) once every other day During a surveyor observation on 6/29/2023 at 9:20 AM, of the resident's wound dressing change, performed by RN, Staff E, revealed the following: - The resident's existing plantar wound dressing was dated 6/25/2023. This treatment was documented as being completed on 6/27/2023 per the June 2023 Treatment Administration Record (TAR). This indicates that the dressing was not changed on 6/27/2023 as documented. - Staff E applied Iodosorb to the resident's plantar wound, which was not ordered. During a surveyor interview on 6/29/2023 at 9:20 AM with Staff E, she acknowledged that she did not follow the physician order for the plantar wound dressing. Additionally, she acknowledged that the resident's existing plantar dressing was dated 6/25/2023. During a surveyor interview on 6/29/2023 at 9:40 AM with the DNS, she acknowledged that Staff E did not follow the physician's order for the plantar wound dressing. Additionally, she was unable to explain why the existing plantar wound dressing was dated 6/25/2023 when it was documented as being changed on 6/27/2023 on the TAR. Refer to Tags:F 684, F 692, F 710.

CRITICAL (J)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Quality of Care (Tag F0684)

Someone could have died · This affected 1 resident

**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 tha...

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**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 relative for 1 of 4 residents reviewed for hospice services, Resident ID #99. Additionally, the facility failed to follow physician's recommendations for 2 of 3 residents reviewed for wounds, Resident IDs #8 and 330, and not following the comprehensive care plan for 1 of 1 resident reviewed for the use of arm sleeves, Resident ID #82. Findings are as follows: 1a. Review of a facility policy titled, Comfort Measures dated April 2015 states in part, .The plan of care will include interventions developed to promote pain management and to address the actual and/or potential physical/emotional/spiritual comfort needs of the resident/patient. According to National Library of Medicine, Adult Dehydration, last updated 2022, indicated that dehydration may complicate other medical problems and may cause significant illness. A resident may appear with dark urine or decreased urine output and may be lethargic upon observation in severe cases of dehydration. Failure to treat dehydration in older adults may lead to significant mortality. The Centers for Disease Control and Prevention does not have defined water intake recommendations, however, adults are encouraged to maintain between 2,000 - 3,000 milliliters per day. Record review of Resident ID #99 revealed that s/he was admitted to the facility in May of 2023 with diagnoses including, but not limited to, malignant neoplasm of the brain (brain cancer) and mild protein calorie malnutrition. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed the resident requires limited assistance with meals of one staff member. Review of a care plan dated 5/25/2023 states in part, .[resident] has no dietary restrictions . Record review revealed a Hospice Care Coordination Note dated 6/19/2023 that revealed the resident is a 1 to 1 feed on a regular, thin liquid diet and ate 100% of breakfast and 75% of lunch. Additionally, it revealed that the resident intermittently refuses meals. Record review revealed an order was transcribed on 6/22/2023 which states, NPO [nothing by mouth]entered by Licensed Practical Nurse (LPN), Staff D. Additional record review revealed the resident did not consume food or fluids for 6 days after the order for NPO was initiated. This order was entered into the medical record by Staff D without authorization by a physician. Review of the resident's meal intake dated 6/21/2023 through 6/27/2023 revealed the following: - 6/21/2023 revealed 26-50% of breakfast eaten, lunch refused by resident and dinner NPO. - 6/22/2023 revealed all three meals charted as not applicable. - 6/23/2023 revealed breakfast and lunch charted as NPO, and dinner charted as not applicable. - 6/24/2023 revealed breakfast and dinner charted as not applicable, and lunch is charted as 0-25% intake. - 6/25/2023 revealed all three meals charted as 0-25% intake. - 6/26/2023 revealed all three meals charted as not applicable. - 6/27/2023 revealed all three meals charted as not applicable. Record review of a progress note dated 6/26/2023, 4 days following the resident being NPO, revealed that the resident had 200 milliliters of concentrated urine output and noted with a terminal ulcer (Kennedy ulcer, wound that occurs during the dying process). Record review of a Hospice Care Coordination Note dated 6/12/2023 revealed the resident was voiding clear, yellow urine via foley catheter. Further review of a hospice progress note dated 6/27/2023, 5 days following the resident being NPO, revealed s/he was now voiding amber urine, which is indicative of dehydration. Record review of a progress note dated 6/28/2023, 6 days following the resident being NPO, revealed the resident expired at 8:20 AM. During a surveyor interview on 6/27/2023 at 11:15 AM with the Hospice Nurse, Staff C, revealed that she did not and would not recommend that a resident at the end of life to be NPO. Additionally, she revealed that hospice would encourage a resident to eat but not force feed the resident. During a surveyor interview on 6/27/2023 at 12:53 PM with the Dietitian, she revealed that she did not recommend the resident to be NPO and that it is not the facility's practice to discontinue food or fluid intake for a resident at the end of life. Additionally, she revealed that she would expect the staff to offer food and fluids for comfort at the end of life. 1b. Review of Mosby's Drug Guide for Nursing Students, Tenth Edition, states in part, dexamethasone .corticosteroid [medication used to stimulate cortisol, an anti-inflammatory hormone produced by the adrenal glands] .Uses: Inflammation .neoplasms, cerebral edema .teach to not discontinue abruptly . Further record review revealed the resident had a physician's order for Dexamethasone twice a day, dated 4/27/2023. This order was also discontinued on 6/22/2023 by Staff D without authorization by a physician. During a surveyor interview on 6/28/2023 at 2:00 PM with Staff D, she acknowledged that she discontinued the Dexamethasone for Resident ID #99. She revealed that she did not obtain a physician's order to discontinue the Dexamethasone. During a surveyor interview on 6/27/2023 at 1:47 PM, and again on 6/30/2023 at 9:06 AM, with the resident's physician, he revealed that he did not give an order to any staff member for the resident to be NPO and did not discontinue the Dexamethasone. Additionally, he revealed that he would not give an order for a resident to be NPO at the end of life and would expect staff to encourage fluid intake as a means of comfort. Furthermore, the physician revealed that he would expect a nurse to obtain orders from him prior to entering it into the medical record. During a surveyor interview on 6/28/2023 at 2:00 PM with Staff D, she revealed that she did not speak to the physician regarding the resident being NPO and did not obtain an order for NPO, or to discontinue the Dexamethasone. Furthermore, Staff D acknowledged that it is not in her scope of practice to write an order without physician authorization. During a surveyor interview on 6/28/2023 at 9:34 AM with the DNS, she acknowledged that Staff D transcribed an order for the resident to be NPO and discontinued the Dexamethasone without obtaining an order from the physician. The system failures of the facility staff entering and following physician orders for its residents, without prior authorization from a physician, unequivocally placed Resident ID #99 at risk for serious harm, impairment or death as food, hydration and significant medications were withheld from him/her for the 6 days that led up to his/her death. 2a. Record review revealed Resident ID #330 was admitted to the facility in June of 2023 with diagnoses including, but not limited to, osteomyelitis (bone infection) and end stage renal disease. Record review revealed a visit report of a wound physician consultation for an evaluation of the resident's wounds dated 6/22/2023 that revealed the resident has an unstageable pressure ulcer to his/her right heel and a diabetic ulcer to his/her right third toe. Further record review of the wound consultation dated 6/22/2023 revealed the following wound physician's recommendations: - The left heel: apply skin prep daily - The right heel: cleanse with Vashe wash (cleansing solution), apply santyl followed by alginate with silver (wound treatment), skin prep to the peri wound, cover with an ABD pad (dressing) and secure with rolled gauze daily. - The right third toe: cleanse with Vashe wash, apply alginate with silver, followed by Medihoney (wound treatment), cover with an ABD pad, and secure dressing with rolled gauze daily. Further record review revealed the following wound treatment orders were entered into the medical record and that did not reflect the wound physician's recommendations: - 6/23/2023 The left heel: cleanse with normal saline, apply santyl to calcium alginate, cover the wound, skin prep peri wound, apply ABD pad, and wrap with kerlix daily - 6/23/2023 The right heel: skin prep to eschar (a slough or piece of dead tissue that sheds off from the surface of the skin after an injury and leave open to air) twice daily - 6/24/2023 The right third toe: cleanse with normal saline, apply Medihoney to calcium alginate, cover the wound, skin prep peri wound, apply ABD pad, and wrap with kerlix daily Record review of the June 2023 Treatment Administration Record (TAR) revealed that the wound treatment orders listed above, which do not reflect the wound physician's recommendations from 6/22/2023, were being documented as completed on the following dates and times: - The left heel: 6/23, 6/25, 6/26, 6/27, 6/28. - The right heel: 6/23 morning and afternoon 6/24 afternoon 6/25 morning and afternoon 6/26 morning and afternoon 6/27 morning and afternoon 6/28 morning - The right 3rd toe: 6/25, 6/26, 6/27, 6/28. Additionally, no treatment was completed on 6/24 During a surveyor interview on 6/28/2023 at 12:03 PM with the DNS, she acknowledged that the resident's current wound treatment orders do not reflect the wound physician's recommendations, including the reversed heel treatments for the left and right heel wound, and the lack of cleansing with Vashe wash and omitting of silver in the right 3rd toe wound treatment. The DNS further acknowledged that the resident's physician was not contacted regarding the wound physician recommendations. Additionally, she revealed the resident's physician always follows the wound physician's recommendations for wound care. 2b. Record review revealed that Resident ID #8 was admitted to the facility in March of 2023 with diagnoses including, but not limited to, type 2 diabetes and muscle wasting. Record review revealed a visit report of a physician wound consultation for an evaluation of the resident's wounds dated 6/22/2023, revealed that the resident has an unstageable pressure ulcer of the left heel and an unstageable pressure ulcer of the buttocks. Further record review of the wound physician consultation dated 6/22/2023 revealed the following wound treatment recommendations: - The left heel: Apply Medihoney Alginate, skin prep eschar, and cover with bordered foam dressing daily - The buttocks: Cleanse with Vashe wash, apply alginate rope (wound treatment), apply Medihoney, and cover with bordered foam dressing daily. Further record review revealed the following wound treatment orders entered that do not reflect the wound physician's recommendations as listed above: - 6/11/2023 The left heel: Apply betadine and leave open to air - 6/16/2023 The buttocks: Remove existing dressing, if existing prisma (wound treatment) is present and is dry, moisten with saline, cover with kerra max bordered dressing (wound dressing), but if the existing prisma is absorbed then apply saline moistened prisma and cover with kerra max bordered dressing once every other day. Record review of the June 2023 TAR revealed that the wound treatment orders listed above, which do not reflect the wound physician's recommendations from 6/22/2023, were being documented as completed on the following dates and times: - The left heel: 6/23, 6/24, 6/25, 6/26, 6/27, 6/28 - The buttocks: 6/24, 6/26, 6/28 During a surveyor interview on 6/28/2023 at 11:39 AM with LPN, Staff G, she acknowledged that the current wound treatment orders do not reflect the most recent wound physician's recommendations. Additionally, she revealed that the resident's physician would follow the wound physician's recommendations. During a surveyor interview on 6/28/2023 at 11:53 AM with the DNS, she acknowledged that the current orders for the resident's left heel and buttocks wounds do not reflect the most recent wound physician's recommendations. She further acknowledged that the resident's physician was not contacted regarding the wound physician's recommendations. Additionally, she revealed that the resident's physician always follows the wound physician's recommendations for wound care. Additional record review revealed that the DNS updated the resident's wound orders to reflect the wound physician's recommendations after it was brought to her attention by the surveyor. 3. Record review revealed that Resident ID #82 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, heart failure and hypertension. Review of a care plan revealed that the resident is at risk for skin breakdown and has left arm edema with bruising. Additionally, the interventions include, but are not limited to, a sleeve to the left arm to protect the skin. During multiple surveyor observations, the resident was observed without a left arm sleeve on the following dates and times: - 6/27/2023 at 10:45 AM and 12:07 PM - 6/28/2023 at 9:06 AM During a surveyor interview on 6/28/2023 at 9:09 AM with LPN, Staff H, she acknowledged that the resident was not wearing the left arm sleeve. During a surveyor interview on 6/29/2023 at 11:30 AM with the DNS, she was unable to provide evidence that the resident was utilizing the left arm sleeve as per the care plan.

CRITICAL (J)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0692 (Tag F0692)

Someone could have died · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident is offered sufficient fluid intake to maintain proper hydration and health for 1 o...

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Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident is offered sufficient fluid intake to maintain proper hydration and health for 1 of 1 residents reviewed for hydration, Resident ID #99. Findings are as follows: According to National Library of Medicine, Adult Dehydration, last updated 2022, indicated that dehydration may complicate other medical problems and may cause significant illness. A resident may appear with dark urine or decreased urine output and may be lethargic upon observation in severe cases of dehydration. Failure to treat dehydration in older adults may lead to significant mortality. The Centers for Disease Control and Prevention does not have defined water intake recommendations, adults are encouraged to maintain between 2,000 - 3,000 milliliters per day. Review of an article published by Medical News Today, titled, How long you can live without water, states in part, .The body needs lots of water to carry out many essential functions, such as balancing the internal temperature and keeping cells alive. As a general rule of thumb, a person can survive without water for about 3 days . Record review for Resident ID #99 revealed that s/he was admitted to the facility in May of 2023 with diagnoses including, but not limited to, malignant neoplasm of the brain (brain cancer) and mild protein calorie malnutrition. Further record review revealed a physician's order dated 5/13/2023 which states in part, Regular diet, Regular Consistency texture, Thin (Regular) Liquids consistency. Review of a care plan dated 5/25/2023 revealed the resident has no dietary restrictions. Additionally, the care plan further stated in part, Staff will provide House regular diet .Staff will provide favorite foods and beverages on request as comfort measure. S/he eats a variety of foods, except fish & shellfish and cereal. [S/he] enjoys most other foods. [Resident ID #99] is open to suggestions for snacks and beverages between meals, and will request as desired. [S/he] enjoys most types of snacks . Record review revealed an order was transcribed on 6/22/2023 which states, NPO [nothing by mouth] documented as administered daily. Record review of the resident's progress notes revealed two notes, dated 6/22/2023 and 6/24/2023, which revealed the resident was documented as being alert and responsive and his/her NPO status was maintained. Further record review of a progress note dated 6/26/2023, authored by the Director of Nursing Services, revealed the resident has had no intake. Record review of the resident's daily intake revealed the resident was documented as NPO or 0-25% intake from 6/22/2023 through 6/28/2023, the day the resident expired. Record review of the resident's urine output revealed the urine output decreased after the NPO order was initiated: 6/19/2023 - 1200 milliliters (mL) 6/20/2023 - 650 mL 6/21/2023 - 625 mL 6/22/2023 -750 mL 6/23/2023 - 420 mL 6/24/2023 - 700 mL 6/25/2024 - 500 mL 6/26/2023 - 150 mL 6/27/2023 - 175 mL 6/28/2023 - 50 mL Record review of a Hospice Care Coordination Note dated 6/12/2023 revealed that the resident had yellow clear urine (indicative of adequate hydration). Record review of the progress note dated 6/26/2023 at 11:01 PM, revealed the resident had concentrated urine (darker urine is indicative of dehydration). Record review of a Hospice Care Coordination Note dated 6/27/2023 revealed that the resident had amber urine (a concentrated urine) and was unresponsive to voice/touch. During a surveyor interview on 6/27/2023 at 8:14 AM, with Registered Nurse (RN), Staff B, she revealed that the resident was NPO due to the resident being on hospice services. During a surveyor interview on 6/27/2023 at 11:15 AM with Hospice RN, Staff C, she revealed that hospice would not have recommended NPO for the resident. She further revealed that hospice would encourage a resident to drink, indicating it is not their practice to recommend NPO status. During a surveyor interview with the Dietitian on 6/27/2023 at 12:53 PM, she revealed that she would expect staff to attempt to offer fluids to the resident. She further revealed that it is not the facility's practice to make a hospice resident NPO. During a surveyor interview on 6/27/2023 at 1:47 PM, with the resident's physician, he revealed that he would not make a resident on hospice NPO. He further revealed he would expect the staff to encourage a resident on hospice to drink for comfort. During a surveyor interview on 6/28/2023 at 2:00 PM, with Licensed Practical Nurse, Staff D, she revealed that she did not obtain a physician's order to change the resident's diet from his/her prescribed regular diet to an NPO status. She acknowledged that she wrote an order for NPO for this resident without contacting the physician. Additionally, she acknowledged it is not within her scope of practice to write an order without a physician's authorization. During a surveyor interview with the Director of Nursing Services on 6/28/2023 at 9:34 AM, she revealed that she would expect staff not to transcribe a physician's order unless it was obtained from a physician. Additionally, she acknowledged that Staff D put in the order for NPO status without obtaining a physician's order, resulting in the resident not eating or drinking for 6 days, and ultimately expiring on 6/28/2023. Furthermore, she was unable to provide evidence that the facility offered sufficient fluid intake to maintain proper hydration for Resident ID #99 as evidence by the resident having decreased concentrated urine output, increase lethargy and ultimately expiring. The system failure of the facility staff entering and following a physician order for its residents, without prior authorization from a physician, unequivocally placed Resident ID #99 at risk for serious harm, impairment or death as nutrition and hydration were withheld from him/her for the 6 days that led up to his/her death. Refer to Tags:F 658, F 684, F 710.

CRITICAL (J)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0710 (Tag F0710)

Someone could have died · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to ensure the medical care of each resident is supervised by a physician for 1 of 4 residents reviewed for e...

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Based on record review and staff interview, it has been determined that the facility failed to ensure the medical care of each resident is supervised by a physician for 1 of 4 residents reviewed for end-of-life care, Resident ID #99. Findings are as follows: 1. Record review revealed Resident ID #99 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, malignant neoplasm of the brain (brain cancer) and mild protein calorie malnutrition. Record review of an order dated 6/22/2023 entered by Licensed Practical Nurse (LPN), Staff D, for NPO [nothing by mouth]. Further record review of the order dated 6/22/2023 for NPO entered by Staff D, was electronically signed through a web application by the resident's physician on 6/24/2023. During a surveyor interview on 6/27/2023 at 1:47 PM, and then again on 6/30/2023 at 9:06 AM with the resident's physician, he revealed that he did not give an order for the resident to be NPO. Additionally, he revealed that the order was digitally signed by him in a batch of orders. Furthermore, he indicated that the orders are not reviewed individually, but are electronically signed all at once via the electronic medical record. Further record review revealed the resident had a physician's order for Dexamethasone (a medication to provide temporary symptomatic relief of symptoms related to increased pressure and edema secondary to brain cancer) twice a day. This order was also discontinued on 6/22/2023 by Staff D without authorization by a physician. Furthermore, the lack of fluid intake paired with the discontinuation of Dexamethasone increases the likelihood of the resident experiencing discomfort from increased intracranial (within the head) pressure secondary to his/her brain cancer. During a surveyor interview on 6/28/2023 at 2:00 PM with Staff D, she acknowledged that she discontinued the Dexamethasone and entered the order for Resident ID #99 to be NPO. She revealed that she did not obtain a physician's order for NPO or to discontinue the Dexamethasone. Additionally, she further acknowledged that it is not in her scope of practice to write an order without physician authorization. During a surveyor interview with the Director of Nursing Services (DNS) on 6/28/2023 at 9:34 AM, she revealed that Staff D entered the order for Resident ID #99 to be NPO and discontinued the Dexamethasone without obtaining a physician's order. Additionally, this failure resulted in Resident ID #99 not consuming food or fluids for 6 days leading up to his/her death. The system failure of having the facility's physicians sign batch orders, rather than individually reviewing them, prevented the resident's physician from reviewing this order two days after it was entered into the resident's medical record in error, which would have allowed the resident to resume eating and drinking prior to his/her death. Additionally, this failure also resulted in the resident not receiving his/her Dexamethasone which was ordered to control the edema and swelling of his/her brain, which placed him/her at risk for an increase in intracranial pressure (can cause headaches and injure your brain or spinal cord). Refer to Tags: F 658, F 684, F 692

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to ensure that self-administration of medications was clinically appropriate...

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Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to ensure that self-administration of medications was clinically appropriate for 1 of 3 residents observed with medications at bedside, Resident ID #74. Findings are as follows: Record review of a facility's policy and procedure titled, Self-Administration of Medication states in part, .If the resident elects to self-administer his/her own medications, an evaluation of their cognitive, physical and visual ability to perform this task is conducted to ensure accurate and safe medication management .Upon admission, readmission, annually, quarterly and change of condition, provide the resident/responsible party with a two-part document entitled SELF-ADMINISTRATION OF MEDICATIONS INFORMED CONSENT AND EVALUATION .Mark the MAR (Medication Administration Record) for each medication being self-administered for daily compliance monitoring purposes. (Indicate that the resident has self-administered) .If there is a change in the resident's status, re-evaluate his/her ability to continue self-administration of medications, as this right may be withdrawn if the resident can no longer safely self-medicate. Record review revealed the resident was readmitted to the facility in March of 2023 with a diagnosis including, but not limited to, osteomyelitis (bone infection) of left hand, right ankle, and foot. Record review of the resident's care plan dated 4/19/2023 revealed s/he chose to self-administer sevelamer (medication that regulates blood phosphorous levels). The intervention included the resident must complete a self-administration evaluation per policy and s/he must keep the medication locked up when not in use. Record review failed to reveal evidence that the resident has received a self-administration evaluation since readmission in March of 2023. Additionally, review of the assessment document titled Self Administration of Medication revealed the resident was coded as No for his/her desire to self-administer medication. During a surveyor observation of the resident's room in the presence of the Director of Nursing Services on 6/29/2023 at 2:05 PM, the resident's bedside drawer was unlocked and the following medications were found: - 41 tablets of sevelamer 800 mg (milligrams) - An opened bottle labeled ibuprofen 200 mg approximately half filled - 1 albuterol sulfate inhaler 90 micrograms - An opened bottle of calcium carbonate tablets approximately half filled During a surveyor interview with the Director of Nursing Services following the above observation, she revealed that she would expect the resident's bedside drawer to be locked. Additionally, she acknowledged that she would expect the facility's policy and procedure to be followed relative to the resident's self-administration of medications.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

**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 the assessment accura...

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**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 the assessment accurately reflected the resident's status for 1 of 1 resident assessed for physical restraints/alarms, Resident ID #5, 1 of 1 resident assessed for weight gain; Resident ID #36, and 1 of 1 resident reviewed for special treatment/procedures, Resident ID #79. Findings are as follows: 1. Record review revealed Resident ID #5 revealed s/he was admitted to the facility in September of 2019 with diagnoses that includes, but are not limited, to schizoaffective disorder (mental health disorder) and borderline personality disorder. During a surveyor observation on 6/27/2023 at approximately 11:30 AM, a wander guard bracelet was observed on his/her wheelchair. Record review of a Treatment Administration Record dated 6/1/2023, through 6/27/2023, revealed the function of the wander guard was checked daily. Record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], Section P, Restraints/Alarms, did not reveal s/he was assessed as having a wander guard in place. During a surveyor interview on 6/28/2023 at approximately 8:45 AM with the Director of Nursing Services (DNS) she revealed Resident ID #5 does have a wander guard in place and indicated that the MDS completed on 5/31/2023 was inaccurate. 2. Record review revealed Resident ID #36 revealed s/he was admitted to the facility in January of 2023 with diagnoses that include, but are not limited to, chronic obstructive pulmonary disease and metabolic encephalopathy (chemical imbalance in the blood that affects the brain). Record review of a weight summary report revealed his/her weight on 2/1/2023 was 136 pounds and on 3/21/2023 his/her weight was recorded at 148.6 pounds; revealing a 9% weight gain in approximately one month. Record review of the MDS, Section K, dated 3/29/2023 revealed s/he was assessed as having a physician prescribed weight loss. During a surveyor interview on 6/28/2023 at approximately 1:00 PM with the Registered Dietitian, she acknowledged that the resident had a significant weight gain and indicated that the MDS assessment dated [DATE] was inaccurate. 3. Record review revealed Resident ID #79 was admitted to the facility in August of 2021 with diagnoses that include, but are not limited to, diabetes and muscle weakness. Record review of the MDS, Section O, dated 4/24/2023 assessed the resident as receiving hospice services. Record review failed to reveal evidence that the resident was receiving hospice services. During a surveyor interview on 6/27/2023 at approximately 12:30 PM with the MDS Coordinator, Staff A, she revealed the MDS was coded inaccurately and the resident was not receiving hospice services.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

**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 that a resident ...

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**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 that a resident receives proper treatment to maintain vision abilities for 1 of 1 resident reviewed, Resident ID #5. Findings are as follows: Record review revealed the resident was readmitted to the facility in September of 2019 with diagnosis including, but not limited to, type 2 diabetes mellitus. During a surveyor interview with the resident on 6/26/2023 at 1:21 PM, s/he revealed that his/her eyeglasses were broken. Record review of the resident's Minimum Data Set assessment dated [DATE] revealed that s/he was coded as, yes for needing corrective lenses (contacts, glasses, or magnifying glass). Record review of the progress note written by the Social Worker, Staff I, on 5/16/2023 revealed that the resident's problem with glasses has been brought to her attention that day. Further review revealed that it was to be followed up with the facility's nurse secretary in the morning. Record review of the resident's nursing progress notes failed to reveal evidence of any follow up relative to his/her broken eyeglasses. During a surveyor interview with Registered Nurse, Staff J, on 6/27/2023 at 12:22 PM, she revealed that the resident was on the list to be seen by the ophthalmologist. Record review of the list of residents who were seen by the optometrist (eye doctor) during her last visit on 6/15/2023 failed to reveal that the resident's name on the list to be seen. During a surveyor interview with the Director of Nursing Services on 6/28/2023 at 12:08 PM, she was unable to provide evidence that the resident's need for replacement eyeglasses was addressed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0694 (Tag F0694)

Could have caused harm · This affected 1 resident

Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to meet professional standards of practice for care related to a peripherally inserted...

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Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to meet professional standards of practice for care related to a peripherally inserted central catheter (PICC) for 1 of 1 residents reviewed for PICCs, Resident ID #330. Findings are as follows: According to an article in the Journal of Infusion Nursing dated 2021, states in part, .1. During the initial flush, slowly aspirate the VAD [Vascular Access Device] for free-flowing blood return that is the color and consistency of whole blood, an important component of assessing catheter function prior to administration of medications and solutions . Record review of a facility provided document titled, Infusion Therapy Nursing Manual states in part, .10 .Attach flushing agent and flush and confirm VAD patency by ease of flushing and verifying a brisk blood return is observed upon aspiration . Record review revealed that the resident was admitted to the facility in June of 2023 with diagnoses including, but not limited to, osteomyelitis (bone infection) and local infection of the skin and subcutaneous tissue. Record review of the Medication Administration Record (MAR) revealed an order with a start date of 6/19/2023 for Piperacillin-Tazobactam (antibiotic) to administer 4.5 grams intravenously two times daily. During a surveyor observation on 6/28/2023 at 11:57 AM of Registered Nurse, Staff B, she was observed flushing the resident's PICC line with 10 milliliters of normal saline and failed to assess for blood return prior to administering the above-mentioned intravenous medication. During a surveyor interview with Staff B immediately following the observation, she revealed that she did not assess for the blood return because the resident did not have an order to assess for blood return. Record review of the resident's MAR failed to reveal an order to assess the resident's PICC line for blood return prior to administering an intravenous medication. During a surveyor interview with the Director of Nursing Services on 6/28/2023 at 12:05 PM, she was unable to provide evidence that the facility followed their protocol relative to PICC line care.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted profe...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principles for 1 of 6 medication carts reviewed and 1 of 3 resident rooms reviewed relative to medication storage for self-administration, Resident ID #74. Findings are as follows: Record review of a facility policy titled, Medication Administration and Documentation-General, states in part, .12. Administers medication at the time it is prepared. (Never pre-pours medications.) . 1. During a surveyor observation on 6/28/2023 at 9:01 AM of Certified Medication Technician (CMT), Staff O during the medication administration task, revealed a clear medication cup within the top drawer of the medication cart labeled, 23B containing 2 pink, oblong tablets and 1 white, oblong tablet. Staff O revealed she found the cup with the 3 medication tablets in the medication cart that morning and was not the individual that pre-poured the medication. She further revealed that she was unsure what the medication was or who it was for. During a surveyor interview on 6/29/2023 at 12:57 PM with the Director of Nursing Services (DNS), she revealed that medication should never be pre-poured. 2. Record review of a facility policy titled, Medication Administration and Documentation-General, states in part, .4. Assures medications are not left unattended. Keeps medications secured in a locked area or in visible control at all times . Record review revealed Resident ID #74 was re-admitted to the facility in March of 2023 with a diagnosis including, but not limited to, osteomyelitis (bone infection) of left hand, right ankle, and foot. Record review of the resident's care plan dated 4/19/2023 revealed s/he chooses to self-administer sevelamer (medication to regulate phosphorous levels) with an intervention including, but not limited to, keeping the medication locked up when not in use. During a surveyor observation on 6/29/2023 at 10:14 AM and 2:05 PM of the resident's room revealed the bedside drawer in the resident's room was unlocked. During the above surveyor observation at 2:05 PM in the presence of the DNS and a second surveyor, revealed the following unsecured medications in the resident's unlocked bedside drawer: - 41 tablets of sevelamer 800 mg (milligrams) - An opened bottle labeled ibuprofen 200 mg approximately half filled without a cover - 1 albuterol sulfate inhaler 90 micrograms - An opened bottle labeled, Tums approximately half filled without a cover During a surveyor interview with the DNS following the above observation on 6/29/2023 at 2:05 PM, she revealed that she would expect the resident's bedside drawer to be locked. She was unable to provide evidence that the facility stored drugs and biological's in accordance with currently accepted professional principles.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident, staff, and resident representative interview, it has been determined tha...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident, staff, and resident representative interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 4 residents reviewed with an indwelling catheter, Resident ID #57. Findings are as follows: Review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument Manual v1.17.1 dated October of 2019, states in part, Indwelling catheters should not be used unless there is valid medical justification. Assessment should include consideration of the risk and benefits of an indwelling catheter, the anticipated duration of use, and consideration of complications resulting from the use of an indwelling catheter. Complications can include an increased risk of urinary tract infection [UTI] .Incontinence also may lead to the potentially troubling use of indwelling catheters, which can increase the risk of life threatening infections .Because of the risk of substantial complications with the use of indwelling urinary catheters, they should be used for appropriate indications and when no other viable options exist. Record review of a facility policy titled, .Urinary Catheter states in part, .Urinary Catheter Change Policy .Urinary catheters should be changed when a urinary tract infection is suspected .A sample for urine culture and sensitivity should be obtained from the new catheter once it is inserted . Record review revealed Resident ID #57 was admitted to the facility in August of 2022 with diagnoses including, but not limited to, urinary tract infection and benign prostatic hyperplasia (BPH; an enlarged prostate) with lower urinary tract symptoms. Record review of an annual MDS assessment dated [DATE] revealed a Brief Interview of Mental Status score of 13 out of 15, indicating intact cognition. Additionally, it further revealed the resident has an indwelling catheter (foley catheter). Record review a physician's order dated 3/25/2023, revealed the foley catheter was indicated for BPH. Record review of the Continuity of Care form from the hospital dated 8/5/2022, indicated that the resident had urinary retention. It further revealed that the resident would follow up with urology for instructions for a trial void (a procedure that assesses a resident's ability to spontaneously urinate after removal of a urinary catheter). Record review revealed the following progress note authored by the Director of Nursing Services (DNS) relative to a urology appointment: - 6/28/2023 at 10:58 AM: .writer called spouse to question the reason [the resident] has a foley [catheter] .Spouse declines to have [the resident] sent out for appointments r/t [relating to] having to pay for transportation . Record review failed to reveal evidence that the facility made an attempt to schedule a urology appointment or conduct a trial void within the facility (which is a common practice in a skilled nursing facility setting) until it was initially addressed by the Director of Nursing Services (DNS) on 6/28/2023, a span of approximately 10 ½ months after the resident was admitted to the facility. Additionally, the urology appointment for a trial void was not addressed with the resident or the resident's spouse, whom has guardianship, until after it was brought to the attention to the facility by the surveyor. Record review of the following progress note revealed the resident developed a urinary tract infection and was subsequently treated with antibiotics: - 10/26/2023 at 11:03 AM: .Started on po ABX [oral antibiotics] r/t + [positive] UTI. Foley in place . Record review failed to reveal evidence that the resident's foley catheter was changed prior to obtaining the urine specimen as per the facility policy. Record review revealed a nursing progress note dated 2/20/2023 indicating the resident had increased confusion and the Nurse Practicitioner ordered a urine specimen to be obtained. Additional review of the progress notes indicated that the facility made attempts to change the foley catheter on 2/17/2023 and 2/18/2023 but the resident refused. Record review failed to reveal evidence that the facility tried to remove the foley catheter to attempt a trial void on the above-mentioned dates, intending only to change and replace the foley catheter to obtain a urine sample. Furthermore, record review revealed that the following nursing progress notes are indicative of a traumatic foley insertion when staff attempted to change the catheter to obtain the urine sample: - 2/20/2023 at 3:25 PM: Attempting to change resident's Foley r/t increased confusion and sediment noted in Foley bag, difficulty with Foley .Supervisor in to help .foley placed .less then 5cc [cubic centimeters] urine return. - 2/20/2023 at 10:48 PM: Noted during shift that it [foley] was only blood draining from resident into [his/her] catheter and no urine in resident urinary bag .catheter pushed further down because resident had BPH and it drained 1500cc of urine. Further record review of the progress notes indicated that the resident's urine specimen resulted positive for a UTI and the resident was subsequently treated with antibiotics for a second time beginning on 2/23/2023. Additionally, the resident had the foley catheter changed and replaced to obtain the urine sample, indicating yet another missed opportunity for the facility to attempt a trial void. Further record review of the above-mentioned progress notes dated 2/20/2023 indicated that the foley catheter was not reassessed for proper placement after having minimal urine output until approximately 7 hours after the initial insertion of the foley catheter. Additionally, the record failed to reveal evidence that the facility notified the physician of the change in condition after the resident developed hematuria (blood in the urine) following the foley catheter insertion. During multiple surveyor observations of the resident throughout the survey process from 6/26/2023 through 6/29/2023, revealed the resident had an indwelling foley catheter. During a surveyor interview on 6/27/2023 at 1:50 PM with the physician, he revealed that the resident's diagnoses of urinary retention and BPH does not support long term foley catheter use. He further revealed he would have expected a trial void for the resident to have already been attempted. Additionally, he indicated he would expect a trial void for the resident to be attempted every few months. During a surveyor interview on 6/28/2023 at 10:04 AM with the resident, s/he revealed they have never had a trial void and would like one. During a surveyor telephone interview on 6/29/2023 at 1:15 PM with the resident's guardian, she revealed that the facility did not notify her or inquire about a urology appointment for the resident until 6/28/2023. She further revealed she was unaware that the resident should have received a trial void. Additionally, she indicated that she wants the facility to attempt a trial void and was unaware that the facility could conduct one. During a surveyor interview on 6/29/2023 at approximately 2:00 PM with the DNS, she revealed trial voids can be conducted at the facility. Additionally, she was unable to provide evidence the facility attempted to arrange for a urology appointment for the resident or attempted to complete a trial void prior to 6/28/2023, after the surveyor brought this concern to the facility's attention. Furthermore, she was unable to provide evidence that the facility provided appropriate treatment and services for Resident ID #57 relative to a foley catheter.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to e...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to ensure that each resident receives adequate supervision to prevent accidents relative to smoking for 4 of 4 residents reviewed, Resident ID #s 26, 78, 103, 112; 1 of 1 resident reviewed relative to the water temperature for bathing, Resident ID #55; 1 of 1 resident reviewed relative to wandering, Resident ID #5; and 1 of 1 resident reviewed for supervision while eating, Resident ID #8. Findings are as follows: 1. Review of the facility policy titled, Smoking states in part, .Smoking will take place under the supervision of a staff member .All cigarettes, igniting and smoking materials will be kept in a secure location designated at the facility, residents are not permitted to retain such items .Smoking will take place under the supervision of a staff member. The staff member will have the responsibility of lighting all cigarettes. a) Record review for Resident ID #103 revealed s/he was admitted to the facility in March of 2022 with diagnoses including, but not limited to, Chronic obstructive pulmonary disease and dementia. Record review of a Nursing Smoking Evaluation and Safety Screen, dated 5/3/2023, revealed that Resident ID #103 is a current smoker and requires supervision during scheduled smoking activity. Record review of the resident's care plan dated 3/19/2022 reveals the resident is a current active smoker. Further record review reveals interventions including, but not limited to, keep all smoking material locked in the smoking cart. Surveyor observations of Resident ID #103 revealed s/he was in possession of smoking materials in his/her room on following dates and times: - 6/26/2023 at 11:33 AM - 6/27/2023 at 11:27 AM - 6/28/2023 at 11:44 AM b) Record review for Resident ID #26 revealed s/he was admitted to the facility in August of 2020 with diagnoses including, but not limited to, dementia with behavioral disturbances and bipolar disorder. Record review of a Nursing Smoking Evaluation and Safety Screen, dated 5/1/2023 revealed that Resident ID #26 is a current smoker and requires supervision during scheduled smoking activity. Review of the resident's plan of care dated 8/26/2020, revealed the following intervention, .keep all smoking materials in locked cart . Surveyor observations of Resident ID #26 revealed s/he was in possession of smoking materials in the basket of his/her electric scooter on following dates and times: - 6/27/2023 at 12:40 PM - 6/28/2023 at 11:39 AM During a surveyor interview with Resident ID #26 on 6/28/2023 at 11:39 AM, s/he acknowledged that s/he goes outside to smoke on a daily basis, and s/he keeps cigarettes and a lighter with him/her. S/he further acknowledged that s/he smokes unsupervised. During this interview cigarettes and a lighter were visible in basket of his/her electric scooter located in the resident's room. c) Record review for Resident ID #78 revealed that s/he was admitted to the facility in July of 2018 with diagnoses including, but not limited to, encephalopathy (brain disease that alters brain function or structure) and alcohol abuse. Record review of a Nursing Smoking Evaluation and Safety Screen, dated 6/30/2023 revealed that Resident ID #78 requires supervision during scheduled smoking activity. Review of the resident's plan of care dated 12/17/2022, revealed the following intervention, .keep all smoking materials locked at reception . During the following surveyor observations, the resident was observed smoking unsupervised on the following dates and times: - 6/27/2023 at approximately 8:00 AM in the side parking lot employee [NAME] area out of sight from the smoking attendant. - 6/27/2023 at 12:48 PM smoking under the green tent out of the sight from the smoking attendant. During a surveyor interview with Resident ID #78 on 6/27/2022 at 12:48 PM, s/he acknowledged that s/he keeps his/her cigarettes and a lighter with him/her at all times. d) Record review for Resident ID #112 revealed that s/he was admitted to the facility in February of 2023 with diagnoses including, but not limited to, metabolic encephalopathy and anxiety. Record review of a Nursing Smoking Evaluation and Safety Screen, dated 5/3/2023 revealed that resident ID #112 requires supervision during scheduled smoking activity. Review of the resident's plan of care dated 3/24/2022, revealed the following, .keep all smoking materials locked in medication room . During a surveyor observation on 6/28/2023 at approximately 10:30 AM, the resident was observed lighting his/her own cigarette. Additionally, the smoking attendant, Staff K, revealed she provided the resident with smoking materials to take to an appointment. During a surveyor interview with the Director of Nursing Services (DNS) on 6/28/2023 at 12:11 PM, she acknowledged that the smoking materials should be kept in a secure location at the facility and she would expect the residents to be supervised while smoking. Additionally, she was unable to explain why Resident IDs #103, 78 and 26 had his/her smoking materials in their possession at the time of the interview. 2. Review of the facility policy titled, Wandering management system states in part, .A wander management system is used for residents/patients at risk for elopement as assessed and determined by the interdisciplinary team .The wander management system bracelet will be applied to the resident's wrist or ankle and not removed until replacement is needed .Check function of [wander guard] on a daily basis. Record review for Resident ID #5 revealed that s/he was admitted to the facility in March of 2018 with diagnoses including, but not limited to, intellectual disabilities, post-traumatic stress disorder, and anxiety. Record review of an Interdisciplinary care plan meeting form dated 6/14/2023, revealed that Resident ID #5 requires a care area for elopement. Review of the resident's care plan dated 1/25/2022, with revision dated 3/10/2022, states the following, The resident is an elopement risk r/t [related to] History of attempt to leave the facility unattended, impaired safety awareness with interventions, including but not limited to, .Distract resident from eloping by offering pleasant diversions, structured activities .WANDER guard back wheel chair behind left arm rest . Record review of resident's Treatment Administration Record (TAR) revealed the following physician's orders: - Check wander guard placement to wheelchair (back of left arm rest): every shift for safety dated 8/18/2022. - Check function for wander guard daily every day shift for safety dated 1/27/2022. During surveyor observations of Resident ID #5 revealed s/he was outside of the building opening the door for arriving visitors on following dates and times without the wander guard alarm being activated: - 6/27/2023 at 7:15 AM - 6/27/2023 at 7:24 AM Record review of a form titled, Risk for Elopement revealed that Resident ID #5's wander guard, that was to be located on the left arm of his/her wheelchair, had an expiration date of 5/2022, which would account for the wander guard failing to alarm when Resident ID #5 was opening the door outside of the building on 6/27/2023. During a surveyor observation in the presence of the Assistant Director of Nursing on 6/28/2023 at approximately 8:40 AM, the resident's wander guard was observed to be expired. During a surveyor interview with the Director of Nursing Services (DNS) on 6/28/2022 at 8:44 AM, she acknowledged that she would expect the wander guard to not be in use past it's expiration date. 3. Review of the facility policy titled, Aspiration Precautions states in part, .Aspiration precautions will be utilized to reduce the risk of aspiration of food or liquid into a resident's lungs .A resident with significant risk of aspiration, which is not completely controlled by current diet modifications, will require Aspiration Precautions by the Interdisciplinary Team . Record review for Resident ID #8 revealed s/he was admitted to the facility in December of 2022 with diagnoses including, but not limited to acute respiratory failure with hypoxia (a condition when the body is deprived of adequate oxygen), pneumonia, and dysphagia (a condition with difficulty in swallowing food). Record review of the MDS assessment dated [DATE], Section G, Functional Status, revealed s/he was assessed as requiring supervision with eating and drinking. Record review of physician order dated 6/16/2023 reveals supervise pt [patient] with all meals. During surveyor observations of Resident ID #8 revealed s/he was eating unsupervised in his/her room on the following dates and times: - 6/26/2023 at 12:55 PM - 6/27/2023 at 9:09 AM - 6/28/2023 at 8:39 AM During a surveyor interview with Licensed Practical Nurse (LPN), Staff G, on 6/28/2023 at 9:04 AM, she acknowledged that the resident was not being supervised during his/her meal. During a surveyor interview with the DNS on 6/28/2023 at 9:39 AM, she indicated she would expect that the staff would follow the physician's order for supervision during meals for Resident ID #8. 4. Record review revealed Resident ID #55 was admitted to the facility in March of 2016. During a surveyor observation on 6/28/2023 at approximately 2:45 PM, Nursing Assistant, Staff L, was observed filling approximately (6) 36-ounce Styrofoam cups with water from the coffee urn in the second floor dining room. During a surveyor interview on 6/28/2023 immediately following the above observation with Staff L, she indicated that the water in Resident ID #55's room was not coming out of the faucet hot and that she was taking the water from the coffee urn to bathe Resident ID #55. Upon this surveyor interview with Staff L, she then dumped the water in the sink when asked why she was disposing of the water, she then stated it was a bad idea. Immediately following this interview the surveyor obtained a temperature of the water from the coffee urn and it was noted to read 170 degrees Fahrenheit. During a surveyor interview on 6/28/2023 at approximately 2:55 PM with the Hospice NA, Staff M, in the presence of the resident immediately following the above observation on 6/28/2023 at approximately 2:50 PM, Staff M indicated that she was completing care for Resident ID #55. She further indicated the water from the faucet in the resident's room was too cold. Additionally, she revealed she would heat the water in basin in the microwave for 1.5 minutes. Furthermore, she revealed she does not check the temperature of the water after microwaving with a thermometer but she does feel it with her hand to ensure its not too hot. During a surveyor interview on 6/28/2023 at approximately 3:00 PM with the Regional Nurse, she indicated it is not an acceptable standard of practice to obtain water from the coffee urn or reheating water in a microwave when bathing residents.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0699 (Tag F0699)

Could have caused harm · This affected most or all residents

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents who are trauma survivors receive trauma informed care in acc...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents who are trauma survivors receive trauma informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences for 5 of 5 residents reviewed, Resident ID #s 5, 11, 50, 76 and 86. Findings are as follows: Record review of a facility policy titled, Trauma Informed Care states in part, .It is the policy of this facility to ensure resident's who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice .4. Documentation regarding the resident's psychosocial well-being including their response to stressful life events/trauma and coping mechanisms will be reflected in the initial Social Service Assessment and/or social service progress notes .5.a trauma informed care plan will be documented in the resident's medical record by social service . 1a) Record review revealed Resident ID #5 was admitted to the facility in March of 2018 with diagnoses including, but not limited to, post-traumatic stress disorder (PTSD), schizophrenia (mental health disorder), anxiety, and major depressive disorder. Record review of a care plan initiated 6/21/2019 for mood and behavior patterns, verbal expressions of distress and or persistent anger to self or others. Further record review failed to reveal evidence of a trauma informed care plan. During a surveyor observation on 6/29/2023 at approximately 9:23 AM, the resident was observed upset in the hallway yelling people are talking too loud covering his/her ears and rocking back and forth. S/he was then overhead yelling no one can help me. During a surveyor interview on 6/29/2023 at 9:35 AM with Licensed Practical Nurse, Staff N, she revealed she was unaware of what caused Resident ID #5's history of trauma. Additionally, she was unaware of what interventions to attempt if the resident experiences a trigger of PTSD. b) Record review revealed that Resident ID #11 was admitted to the facility in January of 2014 with diagnoses including, but not limited to, PTSD, schizophrenia, major depressive disorder, and Alzheimer's disease. Record review of a care plan initiated 4/4/2018 revealed the resident has depression related to disease process of Alzheimer's, major depressive disorder, and PTSD. Further record review failed to reveal evidence of a trauma informed care plan that identifies trauma triggers and interventions. During a surveyor interview on 6/29/2023 at 10:40 AM with the Director of Social Services, she was unable to provide evidence of Resident ID #'s 5 and 11 documentation of their response to stressful life events and coping mechanisms in her assessment or progress notes. c) Record review revealed Resident ID #50 was admitted to the facility in March of 2015 with diagnoses including, but not limited to, PTSD, major depressive disorder, and dementia. Record review of a care plan initiated 6/29/2023 revealed the resident has dementia, major depressive disorder, and PTSD. Further review reveal failed to reveal evidence of a trauma informed care plan that identifies trauma triggers and interventions. d) Record review revealed Resident ID #76 was admitted to the facility in August of 2019 with diagnoses including, but not limited to, PTSD, major depressive disorder, and dementia. Record review of a care plan initiated 8/29/2019 revealed the resident has depression and PTSD. Further record review fails to reveal evidence of a trauma informed care plan that identifies trauma triggers and interventions. e) Record review revealed Resident ID #86 was admitted to the facility in November of 2022 with diagnoses including, but not limited to, PTSD, major depressive disorder, anxiety, and dementia. Record review of a care plan initiated 6/29/2023 revealed the resident has the potential to be physically aggressive when others get too close to him/her in his/her space related to anger. Further record review failed to reveal evidence of a trauma informed care plan that identifies trauma triggers and interventions. During surveyor interview on 6/29/2023 at approximately 2:30 PM with the Regional Nurse, she revealed that the expectation would be for social services to assess residents with a history of trauma and a trauma informed care plan would be developed and implemented per policy.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

**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 tha...

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**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 food is stored, served and distributed, in accordance with professional standards for food service safety relative to the main kitchen and nursing unit kitchenettes. Findings are as follows: 1a. Record review of the manufacturer's instructions for the use of Ready Care Strawberry and Vanilla shakes reads in part .once thawed, refrigerate up to fourteen days . During a surveyor observation on 6/29/2023 at approximately 12:50 PM the refrigerator located on the [NAME] Drive nursing unit revealed eight strawberry shakes without a use by date. During a surveyor observation on 6/29/2023 at approximately 12:55 PM the refrigerator located on the [NAME] Avenue nursing unit revealed four strawberry and eight vanilla shakes without a use by date. An additional surveyor observation on 6/29/2023 at approximately 1:00 PM on the [NAME] Drive nursing unit, a medication cart had a opened eight-ounce container of thick n easy milk with a manufacturer label instruction to discard four days after opening, the eight-ounce container did not have a use by date or a date when opened . 2. The Rhode Island Food Code 2018 Edition 2-402.11 reads in part, .food employees shall wear hair restraints, beard restraints that are designed and worn to effectively keep their hair from contacting exposed food . During a surveyor observation on 6/26/2023 at approximately 9:15 AM, Dietary Aide, Staff R, was observed without a beard restraint while performing tasks in the dish room. An additional surveyor observation on 6/28/2023 at approximately 11:40 AM revealed dietary aide, Staff R, and Cook, Staff S, without a beard restraint while working in the main kitchen. An additional surveyor observation on 6/28/2023 at 11:40 AM revealed Dietary Aide, Staff T, without a hair restraint while working the tray line. 3. The Rhode Island Food Code 2018 Edition 3-501.16 reads in part, Time/Temperature Control for Safety Food, Hot and Cold Holding.food shall be maintained .57 degrees C(135 degrees Fahrenheit) .at 5 degrees C (41 degrees Fahrenheit) . During a surveyor observation on 6/28/2023 at approximately 11:50 AM of the lunch meal on the [NAME] Drive nursing unit the whole milk had a cold holding temperature reading of 64 degrees F. An additional surveyor observation on 6/28/2023 at approximately 12:05 PM the egg salad sandwich had a cold holding temperature reading of 46.4 degrees Fahrenheit. During a surveyor interview on 6/26/2023 at approximately 12:20 PM with the Food Service Director (FSD), he acknowledged the whole milk and egg salad sandwich were not within the acceptable temperature ranges. 4. The [NAME] Food Code 2018 Edition 2-301.14 reads in part, .food employees shall clean their hands immediately before engaging in food preparation .including working with exposed food . During a surveyor observation on 6/26/2023 at approximately 9:30 AM, Dietary Aide, Staff U, was observed wrapping muffins with her bare hands, touching a trash container lid with bare hands, and not washing them prior to wrapping the individual muffins in plastic wrap. 5. The Rhode Island Food Code 2018 Edition 4-501.11, Good Repair and Proper Adjustment states in part: 'Equipment shall be maintained in a state of repair and condition .equipment components such as doors shall be kept .tight . During a surveyor observation on 6/26/2023 at approximately 9:30 AM of the main kitchen the following observations were made: 1. The walk-in refrigerator's light was inoperable 2. The ice cream chest had a high frost accumulation 3. The walk-in freezer unit had frost and ice build up, and the floor of the unit was observed to be rusted. 4. Nine shelves with white epoxy coating that were worn and had rust showing through the end tips. 6. The Rhode Island Food Code 2018 Edition 4.601.11 reads in part, .(A) equipment food contact surfaces .shall be clean to sight . During a surveyor observation on 6/26/2023 at approximately 9:30 AM of the ice machine, the flap where the ice slides down was discolored with a pink film. 7. The Rhode Island Food Code 2018 Edition 4-602.11 reads in part, .equipment food contact utensils shall be cleaned .at any time during the operation when contamination may have occurred .before using .a food temperature measuring device . During a surveyor observation on 6/28/2023 at approximately 11:40 AM of the lunch meal, the FSD recorded an internal food temperature of a piece of fried chicken and without cleaning the thermometer probe, took the internal temperature of a baked chicken breast. 8. The Rhode Island Food Code 2018 Edition 4-601.11 states in part, .nonfood contact surfaces of equipment shall be kept free of an accumulation of dirt .and other debris . During a surveyor observation on 6/26/2023 at approximately 9:30 AM of the dietary storage area a large white container was observed with clean water pitchers, ice scoop holder, insulated hot beverage pitchers sitting on brown particles of debris, and a yellow-colored substance. Further surveyor observation revealed dried brown debris inside the plate warmer and inside the pellet warmer (a piece food service equipment that maintains the temperature of plates during meal service). 9. The [NAME] Food Code Food 2018 Edition 6.501.11 reads in part, .physical facilities shall be maintained in good repair . During a surveyor observation on 6/26/2023 at approximately 9:30 AM the following was observed: - Broken missing tile in the dish room - Ceiling tiles in dish room in disrepair - Pool of gray colored water in dish room by the grease trap During a surveyor interview on 6/28/2023 at approximately 2:30 PM with the FSD, he acknowledged beard and hair restraints were not being worn by dietary staff, repairs were needed in the main kitchen, equipment was in need of cleaning, food storage on the unit kitchenettes needed to be properly dated, and thermometers need to be cleaned between uses.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to establish and maintain an infection prevention and control program designed to pro...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections relative to the handling of a multi-use glucometer for 2 of 2 residents observed, Resident ID #s 333 and 8; and 1 of 1 residents reviewed, Resident ID #7, with a positive wound culture for Methicillin-Resistant Staphylococcus Aureus (MRSA) who was not on proper precautions, and relative to improper technique for a clean dressing change. Findings are as follows: 1. Record review of the Center for Disease Control frequently asked questions for providers safety blood glucose monitoring guidance for providers states, .FDA [Federal Drug Administration] has recently released guidance for manufacturers regarding appropriate products and procedures for cleaning and disinfection of blood glucose meters .The disinfection solvent you choose should be effective against HIV, Hepatitis C, and Hepatitis B virus .Please note that 70% ethanol (alcohol) solutions are not effective against viral bloodborne pathogens . a) Record review revealed Resident ID #333 was readmitted to the facility in June of 2023 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Record review revealed a physician's order dated 6/10/2023 for Insulin Regular inject 18 units in the afternoon for diabetes and to assess the resident's blood glucose level. b) Record review revealed Resident ID #8 was admitted to the facility in December of 2022 with a diagnosis including, but not limited to, type 2 diabetes mellitus. Record review revealed the resident receives insulin injections and has his/her blood glucose levels assessed each day. During a surveyor observation on 6/28/2023 at 11:19 AM of Licensed Practical Nurse (LPN), Staff V, during the medication administration task, revealed Staff V obtained a small basin and placed the glucometer and clean supplies in the basin to bring into Resident ID #333's room. Staff V placed the basin on the resident's bedside table and proceeded to assess the resident's blood glucose level by placing a test strip within the glucometer and drawing blood by puncturing the resident's finger with a lancet and placing the test strip to the drop of blood. Staff V then proceeded to place the uncleaned glucometer with the used test strip back into the basin and returned to the medication cart outside the resident's door, placing the basin on top of the medication cart. She then disposed of the used test strip and cleaned the multi-use glucometer with an alcohol based, non-bleach product. Staff V failed to clean the basin and proceeded to Resident ID #8's room. During a surveyor observation on 6/28/2023 at approximately 11:30 AM of Staff V following the above observation, she placed the medication cart outside of Resident ID #8's room and informed the surveyor she was going to be obtaining his/her blood glucose level. Staff V proceeded to gather all clean supplies and placed them within the unclean, small basin that was previously used for Resident ID #333, and proceeded into Resident ID #8's room until she was stopped by the surveyor. During a surveyor interview on 6/28/2023 at approximately 11:30 AM immediately following the above observation with Staff V, she acknowledged she did not disinfect the basin between use. Additionally, she acknowledged that she did not use a bleach product to disinfect the multi-use glucometer. During a surveyor interview on 6/29/2023 at 12:46 PM with the Director of Nursing Services (DNS), she revealed she would expect that staff disinfect the multi-use glucometer with a bleach product. She further revealed that she would expect that staff not re-use a basin to store dirty and clean supplies for multiple residents. 2. Record review of a facility policy titled, Section I - Isolation states in part, .Transmission-Based Precautions [TBP] .for patients .infected or colonized with infectious agents .require additional control measures to effectively prevent transmission .[TBP] .employed for known or suspected infections .use contact precautions for residents known or suspected to be infected with microorganisms that can be easily transmitted .precautions .discontinued 48 hours after the active signs or symptoms of the infection have resolved .Place Isolation Cart outside the resident's room .Signage will be posted on the door frame or wall outside of the resident room indicating the type of precautions and the required personal protective equipment (PPE) .Multidrug-resistant organisms[MDROs] .infection or colonization .MRSA [methicillin-resistant staphylococcus aureus] .Type of Precaution .Contact + Standard .CONTACT PRECAUTIONS EVERYONE MUST .Put on gloves before room entry .Put on gown before room entry .MDRO Surveillance .should include .listing of residents colonized and/or infected with targeted MDROs .monitor the effectiveness of outbreak control measures . a) Record review revealed Resident ID #7 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, local infection of the skin and subcutaneous tissue (layer of tissue that underlies the skin) and atherosclerosis (hardening and narrowing of arteries) of native arteries of extremities with gangrene (body tissues die due to a lack of blood supply or infection) of right leg. Record review revealed a care plan focus area indicating that the resident has a chronic, non-healing surgical foot wound to his/her right foot with interventions including, but not limited to, treatment as ordered. Record review of a wound culture document of the resident's right foot collected 6/3/2023 revealed the culture resulted positive for MRSA. Further record review failed to reveal evidence that the resident was placed on contact precautions after s/he tested positive for MRSA in his/her wound as per policy. Record review revealed a physician's order dated 6/23/2023 to cleanse the right foot wound daily and as needed with normal saline, apply Medihoney and calcium alginate (wound treatment), and to cover with a dressing and secure with a wrap. During a surveyor observation on 6/27/2023 at 9:41 AM of Licensed Practical Nurse (LPN), Staff W, while conducting the resident's right foot dressing change, she was observed to have conducted the wound dressing change without utilizing appropriate PPE including, but not limited to, a gown for a resident that would require contact precautions as defined in the facility policy above. Additionally, the resident's right foot wound was noted to have saturated the existing gauze dressing with copious amounts of drainage that saturated through the disposable pads and onto the resident's sheet. Record review of a progress note dated 6/27/2023 at 3:54 PM authored by the nurse that completed the resident's right foot dressing change, Staff W, states in part, .wound dressing done per order, had significant amount of drainage bright red blood . During a surveyor interview on 6/27/2023 at 11:29 AM with the Regional Nurse, she revealed she was unsure why the resident was not on precautions relative to testing positive for MRSA in his/her right foot wound. During two surveyor observations revealed that the resident was not on precautions on the following date and times: - 6/27/2023 at 11:33 AM and 12:41 PM During an additional surveyor observation on 6/28/2023 at 8:07 AM, revealed that the resident was on precautions and had a bin of personal protective equipment outside of his/her room, however there was no sign displayed indicating the type of precautions and PPE required to be worn by staff and/or visitors when entering the resident's room. During a surveyor interview on 6/29/2023 at approximately 2:45 PM with the DNS during the exit conference, she revealed she was unaware that the resident's wound culture had resulted positive for MRSA. Additionally, she was unable to provide evidence that the facility provided a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. b) Record review of a facility policy titled, Clean Dressing Technique states in part, Licensed staff members will use clean dressing technique for all dressing changes . During a surveyor observation on 6/27/2023 at 9:41 AM of Licensed Practical Nurse (LPN), Staff W, while conducting Resident ID #7's right foot dressing change, she was observed removing the existing dressing on the resident by cutting it with scissors. She then proceeded to use the same scissors, without disinfecting them, to cut the calcium alginate which was then applied to the wound. During a surveyor interview on 6/27/2023 at 9:54 AM with Staff W following the above-observation, she revealed she should have disinfected the scissors between a dirty and clean dressing change. During a surveyor interview on 6/27/2023 at 11:29 AM with the Regional Nurse, she acknowledged that the nurse should have disinfected the scissors.

Jun 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to provide a written notice of its bed hold policy to the resident or the resident representative prior to t...

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Based on record review and staff interview, it has been determined that the facility failed to provide a written notice of its bed hold policy to the resident or the resident representative prior to the transfer of the resident to the hospital for 1 of 4 sampled residents reviewed, Resident ID #3. Findings are as follows: Record review of a community complaint sent to the Rhode Island Department of Health on 5/1/2023 alleges that the facility has been trying to move Resident ID #3 to a different unit for months and once the resident came back from the hospital s/he was moved to a different unit. The complainant further revealed that once s/he spoke with someone from long-term services and support, s/he learned about a bed hold. Record review for Resident ID #3 revealed that s/he was transferred from the facility to the hospital on 2/2/2023 and returned to the facility on 2/10/2023. Further record review revealed that the resident was transferred to the hospital on 4/18/2023 and returned to the facility on 4/25/2023. Record review failed to reveal evidence that a notice of a bed-hold policy had been provided to the resident or the resident representative upon the resident's transfer to the hospital on 2/2/2023 and on 4/18/2023. During a surveyor interview with Licensed Practical Nurse, Staff A, on 6/6/2023 at approximately 1:20 PM, she indicated that she was unaware that the nursing facility must provide the resident or resident representative, upon transfer to the hospital, a written notice which specifies the state bed hold policy. During a surveyor interview with the Director of Nursing Services on 6/6/2023 at approximately 10:00 AM, she was unable to provide evidence that a written notice of the facility's bed hold policy was given to the resident when s/he was transferred to the hospital on 2/2/2023 and on 4/18/2023.

Mar 2023 6 deficiencies 3 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Deficiency F0692 (Tag F0692)

A resident was harmed · This affected 1 resident

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional status, such a usua...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional status, such a usual body weight or desirable body weight and failed to follow their policy relative to weights, for 1 of 3 residents reviewed, Resident ID #5. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 2/28/2023 alleges in part, Pt [patient] allege .lost 30 lbs [pounds] in the last two months . Review of the facility policy titled, WEIGHTS states in part, .weight loss/gain of 5 pounds or more on a resident weighing 100 pounds or more requires a reweigh for verification. A reweigh is done on the same scale, with a licensed nurse present. Weights are documented in the resident's/patient's medical record and/or weight book. If a significant weight loss/gain is identified (>5% [greater than] in 30 days or >10% in 6 months), the IDT[Interdisciplinary Team], Dietitian, Physician and Family are notified. All residents with a significant weight loss are reviewed by the Interdisciplinary team and the resident/responsible party and interventions implemented as appropriate and are monitored weekly. Record review revealed the resident was admitted to the facility in November of 2022 with diagnoses including, but not limited to, malnutrition and symptoms and signs concerning food and fluid intake. Record review revealed current physician's orders for: - 11/29/2022 Weekly Weight . - 12/2/2022 Ensure Enlive .two times a day .Supplement . Record review of a document titled Weights and Vitals Summary, dated 3/1/2023 revealed the following weights: - 12/6/2022 179.4 Lbs [pounds] - 12/27/2022 166.6 Lbs - 1/31/2023 162.2 Lbs - 2/7/2023 158.4 Lbs - 2/14/2023 155.5 Lbs Additional record review revealed the resident lost 12.8 pounds between 12/6/2022 through 12/27/2022, indicating a significant weight loss of 7.1% in 3 weeks. Further review revealed s/he continued to lose weight, a total of 23.9 pounds between 12/6/2022 through 2/14/2023, indicating a significant weight loss of 13.3% in total in approximately 2 months. Record review revealed the following progress notes: - 2/16/2023 at 10:31 PM authored by the Dietitian .had significant wt [weight] loss of 23.9#[pounds] since admission .Cont [continue] on weekly wt .Intakes vary 0-100% meals .May benefit from use of remeron [medication] to help stimulate appetite . - 2/22/2023 at 2:46 PM authored by the Nurse Practitioner .23.9 lb [pound] weight loss since admission. Weight loss likely attributed to decreased PO [oral] intake .assessed by dietitian with recommendation for Ensure Enlive [supplement] bid [twice daily] .Will strongly consider remeron . Further review of the record failed to reveal evidence that the resident was reweighed for verification, all appropriate parties were notified, that interventions were implemented as per facility policy for significant weight loss or that the remeron was initiated. During a surveyor observation on 3/1/2023 at 12:57 PM revealed the resident asleep in bed with his/her lunch tray on the bedside table untouched. Further observation revealed the diet slip on the tray indicating standing orders for the lunch meal to include 8oz [ounces] of whole milk and 4oz of orange juice, both absent from the tray. During a surveyor interview on 3/1/2023 at 2:27 PM with the Dietitian, she acknowledged the resident has had significant weight loss since admission. She further revealed she was unaware of the significant weight loss of 12.8 pounds between 12/6/2022 and 12/27/2022. Additionally, she revealed she would not implement another intervention because the resident was already started on a supplement prior. Furthermore, she revealed the only additional dietary intervention put in place was a selective menu for the resident after the continued significant weight loss was identified on 2/14/2023. During an additional surveyor interview on 3/1/2023 at 2:40 PM with the Director of Nursing Services in the presence of the Administrator, she was unable to provide evidence the facility adhered to the weight policy or the above-mentioned intervention for remeron was implemented.

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Laboratory Services (Tag F0770)

A resident was harmed · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to meet the needs of the residents regarding timeliness of reporting laboratory results relative to a positi...

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Based on record review and staff interview, it has been determined that the facility failed to meet the needs of the residents regarding timeliness of reporting laboratory results relative to a positive wound culture for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: Record review revealed the resident was readmitted in February of 2023 after a hospitalization that revealed s/he sustained 2 rib fractures and a vertebral (bone of spine) fracture after an unwitnessed fall in the facility. Record review of a care plan focus area revised on 2/25/2023 revealed s/he has pressure ulcers to the coccyx and left heel and is followed by a wound MD (medical doctor) and wound nurse. Further review revealed interventions including, but not limited to, monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx [signs and symptoms] of infection, monitor wound healing and report declines to MD. Record review of several progress notes revealed the following: - 2/2/2023 at 7:03 PM .Weekly wound assessment completed by [wound] MD .STAGE 4 [most severe pressure wound and may expose muscle, tendons, ligaments, cartilage, and/or bone] PRESSURE WOUND COCCYX .Wound progress: Improved. - 2/8/2023 at 9:35 AM .Wound culture from coccyx wound obtained . - 2/10/2023 at 3:52 PM .Wound culture resulted - no new orders . Record review of the resident's coccyx wound culture obtained on 2/8/2023 revealed it was positive for infection. Additional review of the progress notes revealed the resident's coccyx wound had deteriorated as evidenced by the following progress notes: - 2/11/2023 at 5:18 PM authored by the Infection Preventionist, .PRESSURE WOUND COCCYX .Exudate [drainage]: Heavy Purulent [thick, milky discharge containing pus, often indicating infection] .Wound progress: Deteriorated. - 2/14/2023 at 12:55 PM .Weekly wound rounds completed .Wound to coccyx .Surrounding area red .warm to touch .purulent drainage .tender to touch . Additional review of the progress note on 2/14/2023 at 12:55 PM indicated the doctor would be in the facility the following day to assess the wound. Further review of the record failed to reveal evidence that staff reported the deterioration of his/her coccyx wound per the plan of care after staff identified the decline of the resident's wound as noted by the above-mentioned progress notes. Further review of the progress notes revealed the following: - 2/15/2023 at 9:04 AM .Patient complained of increased pain to wound site .MD also reviewed wound culture, would like [wound doctor] to review. - 2/15/2023 at 1:27 PM .Wound culture to coccyx .positive .Reported to Wound MD .Start cipro [antibiotic] . Review of the record revealed the resident began his/her antibiotic treatment for his/her coccyx wound infection on 2/15/2023, indicating that 5 days had elapsed since the facility first discovered the resident's coccyx wound was positive for infection. Additional review of the progress notes revealed the following: - 2/28/2023 at 12:40 PM .Readmit from hospital on risk for wounds . - 3/2/2023 at 10:23 AM authored by the Infection Preventionist, .PRESSURE WOUND COCCYX .Wound progress: Deteriorated .starting abx [antibiotic] therapy r/t [related to] suspected osteomyelitis [infection in a bone] . - 3/2/2023 at 10:59 AM .assessed by Wound Doctor .new orders .DX [diagnosis]: Osteomyelitis to Coccyx Bone Culture Obtained STAT [immediate] STAT labs .Referral for infectious disease faxed .as a high priority . During a surveyor interview on 3/8/2023 at 7:51 AM with the Director of Nursing Services (DNS), she revealed the resident was transferred to the hospital. She further revealed his/her sacral (coccyx) wound is infected and s/he needed a intravenous catheter placed and intravenous antibiotics. During a follow up interview on 3/8/2023 at approximately 1:30 PM with the DNS, she was unable to provide evidence that the wound physician, who ordered the wound culture, was notified in a timely manner to prevent a delay in treatment. Additionally, she was unable to provide evidence that staff reported the deterioration of the coccyx wound to the physician when it was identified per the plan of the care.

SERIOUS (H) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Incontinence Care (Tag F0690)

A resident was harmed · This affected multiple residents

**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 provide appropriate treatment and...

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**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 provide appropriate treatment and services for 1 of 3 residents reviewed with an indwelling catheter, Resident ID #1. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 2/20/2023 revealed that there was an accident that resulted in a hospital admission. Per the report the resident rolled out of bed and was admitted to the hospital with a diagnosis of right rib fractures. Record review of a facility policy titled, .Urinary Catheter states in part, .Urinary Catheter Change Policy .Urinary catheters should be changed when a urinary tract infection is suspected .A sample for urine culture and sensitivity should be obtained from the new catheter once it is inserted . Record review revealed Resident ID #1 was admitted to the facility in December of 2022 with a diagnosis including, but not limited to, acute respiratory failure and was readmitted in February of 2023 after a hospitalization that revealed the resident tested positive for a urinary tract infection (UTI). Record review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15 indicating intact cognition. Record review of the hospital discharge summary document dated 2/22/2023 states in part, .Rib fractures .Compression fracture of T8 vertbra [bone of mid-spine] .Called [facility] .They did not know why [s/he] has a foley [indwelling catheter] or when it was last changed . Further review of the hospital documentation indicated the resident's existing foley had been in place for a total of 78 days prior to the hospital replacing the foley catheter. Record review of a care plan focus area initiated on 12/28/2022 revealed the resident has a foley catheter and is at risk for infection with one of several interventions to change the foley and bag per physician order. Review of the record failed to reveal evidence of a physician's order to change the foley catheter. Record review of the hospital continuity of care (COC) document dated 2/24/2023 revealed a medication list that included Bactrim DS (an antibiotic medication) 800-160 milligrams (mg) to be given 2 times daily for a urinary tract infection beginning on 2/23/2023 at 8:00 PM through 2/28/2023 at 11:59 PM. Additionally, the document indicated the last dose of Bactrim DS administered to the resident was at the hospital on 2/24/2023 at 11:02 AM. Furthermore, it indicated the resident was to receive the next dose of the medication on 2/24/2023 at 8 PM. Record review of the February Medication Administration Record (MAR) failed to reveal evidence that the order for Bactrim DS was transcribed as ordered per the hospital COC document indicating the resident did not receive the remaining 9 doses of the antibiotic for his/her urinary tract infection. Record review revealed the following progress notes preceding the hospitalization: - 2/1/2023 at 6:57 PM .very confused .thinks [s/he] is at .sons house .hearing kids playing downstairs .does not know where [s/he] is . - 2/2/2023 at 11:20 AM .lab results reported .start Ciprofloxacin [antibiotic] .x 7 days .continue to monitor. - 2/4/2023 at 8:03 PM .noted confusion .Cipro [ciprofloxacin] .r/t [related to] UTI [urinary tract infection] . - 2/17/2023 at 7:35 AM .found on floor .was trying to get [his/herself] back into bed despite already being in bed already .sent out to [hospital] . Record review of the February 2023 MAR revealed the resident was treated with antibiotics for a UTI beginning on 2/2/2023 after the facility obtained a urine specimen without replacing the catheter per the facility policy for a suspected UTI. Further review of the February MAR failed to reveal evidence the resident received his/her antibiotic on 2/3/2023 at 8:00 PM. Additional record review indicated the resident continues with increased confusion and hallucinations and revealed the following nursing progress notes: - 2/24/2023 at 10:31 PM .had a rough night .very confused .[s/he] though [sic] [s/he] was in [his/her] old house . - 2/26/2023 at 6:10 AM .Patient agitated .exhibited extreme poor safety awareness .reaching towards floor from the bed .confused and hallucinating .combative . During a surveyor interview on 2/28/2023 at 11:00 AM with the Director of Nursing Services (DNS), she revealed only the foley catheter bag is changed prior to obtaining a urine specimen from an indwelling catheter. She was unable to provide evidence the foley catheter was changed prior to obtaining the urine specimen as per policy. During a subsequent interview on 3/1/2023 at 11:35 AM with the DNS, she revealed the resident had completed his/her antibiotic course for the UTI in the hospital and no longer required the medication. During a surveyor interview on 2/28/2023 at 2:18 PM with the physician, he revealed he would expect long term foley catheters to be changed at least monthly. During a follow up surveyor interview on 3/1/2023 at 1:44 PM with the physician, he revealed he was unaware the resident was to continue antibiotics for a UTI upon return to the facility and missed a total of 9 doses until brought to his attention by the surveyor. Additionally, he revealed he would order another urine specimen if the patient continued to exhibit symptoms.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

**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 provide ne...

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**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 provide necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for 1 of 3 residents reviewed, Resident ID #1. 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, type 2 diabetes and malnutrition. Record review of a Minimum Data Set (MDS) assessment dated [DATE] revealed the resident has 2 unhealed pressure ulcers. Additionally, s/he requires an extensive assist of 2 people for repositioning while in bed. Record review of a care plan focus area revised on 2/25/2023 revealed s/he has pressure ulcers to the coccyx and left heel with interventions including, but not limited to, administer treatments as ordered. Record review of current physician orders revealed an order dated 12/22/2022 for off loading booties when in bed. During surveyor observations of the resident revealed s/he was in bed without the off-loading booties applied as ordered on the following dates and times: - 2/27/2023 at 11:37 AM and 2:01 PM - 2/28/2023 at 8:34 AM During a subsequent observation and interview on 2/28/2023 at 8:44 AM in the presence of Licensed Practical Nurse, Staff A, she acknowledged that the booties were not in place while the resident was in bed. Additionally, she revealed the resident is to be wearing the booties to his/her feet while in bed. Furthermore, Staff A applied the booties to the resident's feet only after it was brought to her attention by the surveyor. During a surveyor interview with the Director of Nursing Services on 2/28/2023 at 10:55 AM, she was unable to provide evidence that the staff is consistently following treatment orders relative to promoting the healing of current pressure ulcers.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from any significant medication errors for 1 of 3 residents reviewed for m...

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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from any significant medication errors for 1 of 3 residents reviewed for medication administration, Resident ID #1. Findings are as follows: Record review revealed the resident was admitted to the facility in December of 2022 with diagnosis including, but not limited to, acute respiratory failure, heart failure, atrial fibrillation (abnormal heart rhythm), and fibromyalgia (chronic disorder that causes pain in muscles and soft tissues). Record review revealed the following physician orders: - 12/14/2022 Atorvastatin Calcium Tablet 40 MG Give 1 tablet .at bedtime .related to HEART FAILURE .7 PM - 12/14/2022 Senna-Docusate Sodium Tablet 8.6-50 MG .Give 2 tablet .at bedtime for constipation .7 PM - 12/14/2022 Apixaban Tablet 5 MG Give 1 tablet .two times a day related to HEART FAILURE .2000 [8 PM] - 12/14/2022 Gabapentin .100 MG .Give 1 capsule .two times a day for pain .2000 [8 PM] - 12/14/2022 Qvar RediHaler .40 MCG .2 puff inhale .two times a day for respiratory insufficiency .2000 [8 PM] - 12/14/2022 Torsemide Tablet 20 MG Give 1 tablet .two times a day related to HEART FAILURE .2000 [8 PM] - 12/15/2022 Spironolactone Tablet 25 MG Give 0.5 tablet .at bedtime related to HEART FAILURE .2100 [9 PM] - 2/2/2023 Ciprofloxacin .Tablet 250 MG .Give 1 tablet .two times a day for infection for 7 Days .2000 [8 PM] - 2/2/2023 Probiotic .250 MG .Give 1 capsule .two times a day for Antibiotic therapy for 14 Days .2000 [8 PM] Record review of the February Medication Administration Record (MAR) failed to reveal evidence the resident received the above-mentioned medications as ordered on 2/3/2023 or that the physician was notified. During a surveyor interview on 2/28/2023 at 2:18 PM with the physician, he revealed he would expect to be notified if a resident did not receive medications as ordered. During a surveyor interview with the Director of Nursing Services on 3/1/2023 at 11:35 AM, she revealed the resident did not receive the above-mentioned medications on 2/3/2023 due to his/her increased lethargy.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to follow their infection control program to prevent the spread of infection and to e...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to follow their infection control program to prevent the spread of infection and to ensure a sanitary environment to help prevent the transmission of infections for 2 of 3 residents reviewed on contact precautions, Resident ID #s 1 and 4. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 2/20/2023 revealed that there was an accident that resulted in a hospital admission. Per the report the resident rolled out of bed and was admitted to the hospital with a diagnosis of right rib fractures. Record review of a facility policy titled, Section I - Isolation states in part, .Transmission-Based Precautions [TBP] .for patients .infected or colonized with infectious agents .require additional control measures to effectively prevent transmission .[TBP] .employed for known or suspected infections .use contact precautions for residents known or suspected to be infected with microorganisms that can be easily transmitted .precautions .discontinued 48 hours after the active signs or symptoms of the infection have resolved .Place Isolation Cart outside the resident's room .Signage will be posted on the door frame or wall outside of the resident room indicating the type of precautions and the required personal protective equipment (PPE) .Multidrug-resistant organisms[MDROs] .infection or colonization .MRSA [methicillin-resistant staphylococcus aureus] .ESBLs [extended spectrum beta-lactamases] .Type of Precaution .Contact + Standard .CONTACT PRECAUTIONS EVERYONE MUST .Put on gloves before room entry .Put on gown before room entry .MDRO Surveillance .should include .listing of residents colonized and/or infected with targeted MDROs .monitor the effectiveness of outbreak control measures . 1. Record review revealed Resident ID #1 was admitted to the facility in December of 2022 with a diagnosis including, but not limited to, acute respiratory failure and was readmitted in February of 2023 after a hospitalization that revealed the resident tested positive for a urinary tract infection and confirmed ESBL in his/her urine. Record review of nursing progress notes revealed the following: - 2/17/2023 at 7:35 AM .Resident was found on floor .sent out to [hospital] . - 2/18/2023 at 6:13 AM .admitted for fall . - 2/24/2023 at 10:00 PM .discharge from [hospital], came back .meds reviewed . Record review of the hospital continuity of care (COC) document dated 2/24/2023 revealed a medication list that included Bactrim DS (an antibiotic medication) to be given 2 times daily for a urinary tract infection through 2/28/2023. Further review of the hospital documentation revealed his/her urine culture was positive for ESBL which requires contact precautions per facility policy. Surveyor observations on 2/28/2023 revealed Resident ID #1 without signage posted outside his/her door or an isolation bin outside his/her room on the above date during the following times: - 8:44 AM - 10:55 AM During a surveyor interview with the Director of Nursing Services (DNS) in the presence of the Infection Preventionist on 2/28/2023 at 11:00 AM, she revealed she was unaware Resident ID #1 had an active urinary tract infection and that his/her urine culture tested positive in the hospital for ESBL until brought to her attention by the surveyor. Additionally, she revealed s/he should be on contact precautions. During a subsequent surveyor observation on 2/28/2023 at 2:22 PM in the presence of Licensed Practical Nurse (LPN), Staff B, she acknowledged Resident ID #1's room was still without signage or an isolation bin outside his/her room, indicating approximately 3.5 hours had elapsed since the surveyor had brought the ESBL positive lab result to the attention of the DNS. Additionally, Staff B revealed she was unaware s/he required contact precautions. 2. Record review for Resident ID #4 revealed s/he was admitted to the facility in December of 2017 with a diagnosis including, but not limited to, bacteremia (presence of bacteria in the blood). Record review of a progress note dated 2/23/2023 at 7:32 AM revealed s/he was on contact precautions for MRSA of the foot. During a surveyor observation and immediate interview on 2/28/2023 at 12:27 PM with Staff B, she acknowledged there was no signage posted outside his/her door indicating the type of precautions and PPE required prior to entering his/her room. Additionally, she revealed s/he was on contact precautions for MRSA of a right foot wound. During a subsequent observation on 2/28/2023 at 2:22 PM in the presence of Staff B, she acknowledged Resident ID #4's room without signage posted outside his/her door indicating approximately 2 hours had elapsed since the lack of signage was brought to her attention. During a follow up surveyor interview on 2/28/2023 at 2:40 PM with the DNS, she was unable to provide evidence the facility was following their policy relative to residents on contact precautions to ensure a sanitary environment to help prevent the transmission of infections.

Dec 2022 1 deficiency 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Deficiency F0760 (Tag F0760)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, it has been determined that the facility failed to ensure that residents ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, it has been determined that the facility failed to ensure that residents are free from any significant medication errors for 1 of 3 resident's reviewed for medication administration, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 12/20/2022 alleges in part, .the facility did not order [the resident's] suboxone [a medication used to treat opioid dependence, abrupt discontinuation may cause withdrawal symptoms including, but not limited to, nausea, vomiting, and anxiety]. He had to go to the ER [emergency room] in order to receive his required dose . Record review revealed the resident was admitted to the facility in November of 2021 with diagnoses including, but not limited to, pain in right knee, pain in right lower leg, opioid use, and post-traumatic stress disorder. Review of the resident's Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMs) score of 15/15, indicating intact cognition. Record review of the resident's care plan dated 12/8/2021 revealed .potential for pain .Administer pain medications as ordered. Review of a hospital document dated 12/20/2022 states in part, presents to the emergency department with withdrawal and in need of [his/her] suboxone dose .At present, pt [patient] reports [s/he] is starting to go through withdrawals now with abdominal pain [s/he] appears to be in withdrawal .will check urine and give [him/her, his/her] Suboxone dose . Review of the resident's progress notes revealed the following: -12/20/2022 8:19 AM- .no buprenorphine [a medication used to treat opioid use disorder and chronic pain] available for this resident. pharmacy called and [prescribing physician] called again regarding script this morning. Resident states he is going to call 911 and go to the hospital for his dose at this time. -12/20/2022 13:34- .resident to return from [hospital] .Buprenorphine dose given in the ED [emergency department]. [prescribing physician] will send script to pharmacy this afternoon and facility will have next dose on hand. Review of the resident's December Medication Administration Record (MAR) revealed an order with a start date of 9/21/2022 for Buprenorphine HCL Tablet Sublingual [under the tongue] 8MG [milligram] Give 24 mg sublingually in the morning for pain. Further review of the MAR failed to reveal evidence the resident received Buprenorphine HCL tablet at the facility on 12/20/2022 as ordered. Record review of the unit narcotic count book revealed that on 12/19/2022 the quantity remaining was zero for Buprenorphine 8 mg tablets and it was not delivered to the facility until 12/21/2022. Review of a document provided by the facility titled, Controlled Substance Ordering states in part, Please anticipate your needs- do not wait until the patient is completely out of medication to start the process in the case of chronic use controlled substances. Record review failed to reveal evidence any effort was made to obtain the medication Buprenorphine prior to being completely out of the medication on 12/19/2022. During a surveyor interview with the complainant on 12/22/2022 at 9:45 AM, she indicated that because the facility failed to provide the resident with his/her medication resulting in the resident going to the hospital for the medication. During a surveyor interview with the resident on 12/22/2022 at approximately 10:10 AM, s/he revealed that s/he did not receive Buprenorphine on the morning of 12/20/2022 which resulted in him/her feeling sick and vomiting. Additionally, s/he revealed this missed medication dose was stressful and s/he felt that there was no choice but to go to the hospital for the medication on 12/20/2022. During a surveyor interview on 12/22/2022 at 10:40 AM with Licensed Practical Nurse (LPN) Staff A, he revealed the facility did not have Buprenorphine on hand on 12/20/2022 and that the resident's dose was not administered as ordered. During a surveyor interview on 12/22/2022 at 1:04 PM with the office manager at the prescribing physician's office, she revealed the first time the facility attempted to contact the doctor to refill this prescription was on 12/19/2022. She further revealed she would have expected the facility to contact the office to request a refill prior to running out of the medication. During a surveyor interview with the Director of Nursing Services on 12/22/2022 at 2:56 PM, she acknowledged the resident did not receive his/her dose of Buprenorphine at the facility on 12/20/2022 as ordered. She further acknowledged that the facility did not have the medication available at the time it was due to be administered on 12/20/2022. Additionally, she was unable to provide evidence that Resident ID #1 was free from any significant medication errors.

Dec 2022 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, and staff interview, it has been determined that the facility failed to provide reasonable acc...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, and staff interview, it has been determined that the facility failed to provide reasonable accommodation of resident needs and preferences, relative to the resident's shower for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of a community reported complaint, submitted to the Rhode Island Department of Health on 12/7/2022 alleges that many of the CNAs (Certified Nursing Assistants) do not clean the residents well. When s/he asks to be cleaned, the CNAs state that they already have. Record review revealed the resident was admitted to the facility in July of 2022 with diagnoses including, but not limited to, muscle weakness, disorder of muscle, other disorder of bone density and structure, muscle wasting and atrophy. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 14 indicating the resident is cognitively intact. Record review of the admission MDS assessment dated [DATE] revealed that the resident prefers showers for bathing. Record review of the facility document titled Task: bath/shower revealed his/her shower is scheduled weekly on Thursdays on the 7-3 shift. Further review of this document from 11/21/2022 to 12/9/2022 revealed that s/he received a shower once on 11/22/2022. During a surveyor interview with the resident on 12/9/2022 at 11:00 AM, s/he revealed s/he has not received a shower for 2 weeks and would like to have one. During a surveyor interview with a CNA, Staff A, on 12/9/2022 at 11:08 AM, she indicated that she cared for this resident for a week and did not provide him/her with a shower. During a surveyor interview with the Director of Nursing on 12/9/2022 at approximately 2:30 PM, she was unable to provide evidence that his/her preferences for a shower were accommodated.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**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 implement a comprehensive person-...

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**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 implement a comprehensive person-centered care plan for 2 of 3 residents reviewed for mechanical lifts, Resident ID #s 1 and 2. Findings are as follows: 1. Record review revealed Resident ID #1 was admitted to the facility in July of 2022 with diagnoses including, but not limited to, muscle weakness, disorder of muscle, other disorder of bone density and structure, muscle wasting and atrophy. Record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident requires a Hoyer an (assistive device that allows patients to be transferred between a bed and a chair or other similar resting places) as an assistive device. Review of his/her care plan failed to reveal evidence on how staff are to safely transfer this resident or that the use of a Hoyer lift is needed. During a surveyor interview with the Certified Nursing Assistant (CNA), Staff A on 12/9/2022 at approximately 11:10 AM, she revealed that she asks the residents how to take care of them. She further indicated if the resident is not verbal, she guesses what their needs are. During a surveyor interview with the Licensed Practical Nurse (LPN), Staff B, on 12/9/2022 at approximately 11:30 AM, he was unable to provide evidence on how staff are to safely transfer this resident or that the use of a Hoyer lift is needed. He further acknowledged that the care plan failed to reflect the resident's assessment. During a surveyor interview on 12/9/2022 at approximately 3:00 PM with the Director of Nursing Services, she was unable to provide evidence that the care plan indicated on how staff are to safely transfer this resident or that the use of a Hoyer lift is needed. 2. Record review revealed Resident ID #2 was admitted to the facility in March of 2021 with diagnoses including, but not limited to, disease of spinal cord, muscle wasting and atrophy, muscle disorder and dysthymic disorder. Record review of the resident's quarterly Minimum Data Set assessment dated [DATE] revealed Brief Interview for Mental Status (BIMS) score of 15 indicating this resident's cognition is intact. Record review of a facility document titled PT evaluation and plan of treatment dated 10/4/2022 revealed transfers equal total dependence .mobility with Hoyer lift for this resident. Review of Resident ID # 2's care plan failed to reveal evidence on how staff are to safely transfer him/her or that the use of a Hoyer lift is needed for this resident. During a surveyor interview with the resident on 12/9/2022 at 10:13 AM, s/he revealed that it takes two CNAs to get him/her out of bed because s/he is transferred via a Hoyer lift. During a surveyor interview with the Director of Nursing Services on 12/9/2022 at approximately 3:00 PM, she was unable to provide evidence that this resident's care plan reflected how to transfer him/her.

Nov 2022 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from any significant medication errors for 1 of 4 residents reviewed, Resi...

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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from any significant medication errors for 1 of 4 residents reviewed, Resident ID #4. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 11/14/2022, alleges that the resident did not receive his/her afternoon Clonazepam dose during his/her stay at this facility. Record review revealed the resident was admitted to the facility in October of 2022 with diagnoses which include but are not limited to: Individual with developmental disabilities; Lennox-Gastaut syndrome (epilepsy); acute respiratory failure with hypoxia and hypercapnia; pulmonary collapse; and severe sepsis with septic shock. Record review of a hospital Continuity of Care Form (a form used by the hospital to communicate information pertaining to the resident's hospital stay and discharge instructions), dated 10/14/2022, revealed an added order for Clonazepam (medication used to control seizures and anxiety), 2 milligrams (MG), 1 tablet, to be administered in the afternoon. Record review of the October and November 2022 Medication Administration Records failed to reveal evidence that this resident received his/her ordered afternoon dose of Clonazepam from 10/14/2022 through 11/10/2022, for a total of 28 missed doses. During a surveyor interview with the Director of Nursing Services on 11/15/2022 at 10:30 AM, she was unable to provide evidence that the resident received his/her afternoon Clonazepam doses as ordered by the hospital.

Orchard View Manor

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Orchard View Manor

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