What is Greenville Skilled Nursing and Rehabilitation's CMS rating?

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

Does Greenville Skilled Nursing and Rehabilitation have any serious inspection findings?

Yes, Greenville Skilled Nursing and Rehabilitation has 6 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 51 total deficiencies from recent inspections.

What are the staffing levels at Greenville Skilled Nursing and Rehabilitation?

Greenville Skilled Nursing and Rehabilitation has a five-star staffing rating from CMS with 0.96 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

How many beds does Greenville Skilled Nursing and Rehabilitation have?

Greenville Skilled Nursing and Rehabilitation has 131 certified beds.

Who owns Greenville Skilled Nursing and Rehabilitation?

Greenville Skilled Nursing and Rehabilitation is a for profit - corporation facility and is part of the GENESIS HEALTHCARE chain.

Was Greenville Skilled Nursing and Rehabilitation ever fined?

Yes, Greenville Skilled Nursing and Rehabilitation has been fined $274,339 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is Greenville Skilled Nursing and Rehabilitation on any federal watch list?

No, Greenville Skilled Nursing and Rehabilitation 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 Greenville Skilled Nursing and Rehabilitation?

Medicare inspectors have found 51 deficiencies at Greenville Skilled Nursing and Rehabilitation: 6 critical, 5 serious, 39 moderate, 1 minor. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting Greenville Skilled Nursing and Rehabilitation?

Families visiting Greenville Skilled Nursing and Rehabilitation 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 Greenville Skilled Nursing and Rehabilitation compare to other nursing homes?

Greenville Skilled Nursing and Rehabilitation 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.

Greenville Skilled Nursing and Rehabilitation | 0/100 (Grade F)

Apr 2025 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

Accident Prevention (Tag F0689)

A resident was harmed · 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 each reside...

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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 each resident receives adequate care to prevent an accident for 1 of 1 resident reviewed with an injury of unknown origin, Resident ID #2, and for 1 of 1 resident reviewed who experienced an actual fall, Resident ID #3. Findings are as follows: 1. Review of a facility reported incident submitted to the Rhode Island Department of Health on 4/10/2025 revealed Resident ID #2 sustained an injury of unknown origin to his/her left lower leg during care and was sent to the hospital for an evaluation .large, deep half circle with moderate bleeding . The report further indicated that the resident returned to the facility with sutures to the wound. Review of a facility policy titled, Safe Resident Handling/Transfer Equipment states in part, Safe Resident Handling involves the use of assistive devices to ensure that patients can be transferred safely .A Gait Belt [a safety device that wraps around a resident's waist to assist with safe transfers] is used with patients who can .perform stand pivot transfer with limited/minimal assistance with one staff member . Record review revealed Resident ID #2 was originally admitted to the facility in July of 2024 with a diagnosis including, but not limited to, Alzheimer's Disease, dementia, difficulty in walking, and unsteadiness on feet. Record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident is usually understood, experiences difficulty communicating some words or finishing thoughts, but is able if prompted or given time. Additionally, it reveals that s/he sometimes understands and can respond adequately to simple, direct communication only. Further review revealed the resident requires supervision or touching assistance (a helper to do less than half of the effort. Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for chair/bed-to-chair transfers and to go from sitting to standing. Record review of the resident's [NAME] (a documentation system that enables nurses to write, organize, and easily reference key resident information that shapes their nursing care plan) reveals the resident requires a partial assist, substantial assist to safely transfer to and from a bed to a chair/wheelchair. Record review failed to reveal evidence of a physician's order with indications on how the resident transfers. Review of the [unit name redacted] Unit Ambulation/Transfer log, states in part, [Resident ID #2] assist of 1 for transfers w[with] walker. Record review of a progress note dated 4/9/2025 revealed the nurse was called to the resident's room by a Nursing Assistant (NA) when a large, deep, half circle wound was noted with moderate bleeding. The on-call provider was notified, and the resident was transferred to the hospital for sutures. Record review of the hospital documentation dated 4/9/2025 revealed the resident was evaluated for a large wound on his/her left leg. Further review revealed 13 sutures were placed to close the wound. During a surveyor interview on 4/15/2025 at 1:21 PM with NA, Staff D, she indicated that on the evening of 4/9/2025, she completed upper body care for the resident but was asked by the nurse to assist with another resident who was getting an x-ray. Staff D then revealed that she asked NA, Staff E to assist the resident with a transfer to bed because he had previously offered to help. Additionally, she revealed that when she returned to the resident's room, 10 minutes later, the resident was in bed with his/her pants and shoes still on, she noticed blood seeping through the resident's pants and onto the bed and then the new wound to the resident's left lower leg was identified. Furthermore, Staff D revealed that had the resident been bleeding prior to being transferred to bed she would have noticed it while providing him/her with upper body care. Record review of an undated written statement authored by NA, Staff E, revealed in part, that he was watching the dining room, when Staff D asked him to help transfer Resident ID #3. Staff E revealed that Staff D then went to help another resident and he was relieved from watching the dining room, so he went to Resident ID #3's room and transferred him/her to bed. The statement further reveals that the resident was combative, and he left him/her in bed with his/her clothes on so Staff D could take care of him/her. During a surveyor interview on 4/15/2025 at 1:30 PM with NA, Staff E, he indicated that on 4/9/2025 around 6:45 PM, he transferred the resident from his/her wheelchair into his/her bed by holding the resident's upper arm as the resident was holding onto the bedrail. He further indicated that he did not use a walker or a gait belt for the transfer. Additionally, he indicated that he did not notice any bleeding during the transfer and did not remove any of the resident's clothes, as s/he was not on his assignment, and he was only helping to transfer him/her into bed and then left the room. During a surveyor interview on 4/15/2025 at approximately 3:00 PM with the Director of Nursing Services, she indicated that she would expected a walker and a gait belt to have been utilized when Staff E transferred Resident ID #2 on the evening of 4/9/2025. The result of the facility's failure to utilize a walker and to implement their safe resident handling policy by applying a gait belt to the resident resulted in Resident ID #2 being transferred to the hospital for an evaluation of a new wound to his/her left lower leg and receiving 13 sutures. 2. Review of a facility reported incident submitted to the Rhode Island Department of Health on 4/14/2025 revealed Resident ID #3 had a new onset of hip pain, and the resident reported that s/he had an unwitnessed fall. The resident was admitted to the hospital with a left hip fracture. Review of a facility policy titled, Falls Management states in part, .Patients experiencing a fall will receive the appropriate care and post-fall interventions will be implemented .Implement and document patient-centered interventions according to individual risk factors in the patient's plan of care . Record review revealed Resident ID #3 was admitted to the facility in February of 2025 with diagnoses including, but not limited to, dementia, muscle weakness, and a history of falls. Record review of the MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. Further review revealed the resident was independent with transfers and ambulation. Record review of a progress note dated 4/7/2025 revealed a bruise was noted to the resident's left bicep measuring 4 centimeters (cm) by 3.75 cm. Record review revealed a Change in Condition [CIC] Evaluation dated 4/8/2025 was completed due to an unwitnessed fall resulting in a bruise that was noted to be purple and blue in color. Further review revealed no other injuries were noted. Record review of a care plan dated 2/15/2025 revealed the resident is at risk for falls. Further review failed to reveal evidence that an intervention had been put into place to prevent falls following the resident's unwitnessed fall on 4/7/2025. Record review of an After Hours Telehealth Consult dated 4/12/2025, revealed the resident had an unwitnessed fall, complained of left hip pain and is unable to raise the left leg. Further review revealed the resident would not allow the nurse to touch his/her leg, however, the supervisor noted the left leg to be shorter than the right with the left hip externally rotated. Additional review revealed an order was given to transfer the resident to the hospital for an evaluation. Record review revealed a CIC Evaluation was completed on 4/12/2025 for a fall resulting in left hip pain and outward rotation. Further review revealed the resident stated that s/he had fallen. Record review of the hospital documentation dated 4/15/2025 revealed the resident was admitted to the hospital following a fall and was found to have a left hip fracture and a urinary tract infection. Further review revealed surgery was completed to repair the hip. Additionally, the resident was discharged back to the facility on 4/15/2025. During a surveyor interview on 4/16/2025 at approximately 10:00 AM with the Nursing Educator, she indicated that she was working the floor on 4/7/2025 when the bruise was noted to the resident's bicep and that the resident had reported that s/he fell. She further indicated that an unwitnessed fall was assumed to be the cause of the bruise, and a CIC evaluation was completed. She further acknowledged that no new fall interventions were put into place following the unwitnessed fall on 4/7/2025. During a surveyor interview on 4/16/2025 at 10:50 AM with the Director of Nursing Services, she indicated that she would expect new interventions to be put into place following an unwitnessed fall. During a surveyor interview on 4/16/2025 at 11:30 AM with the Administrator, she indicated that Physical Therapy (PT) was going to evaluate the resident that day and that the care plan was updated late. She further indicated that the resident had not been evaluated by PT after the resident's unwitnessed fall on 4/7/2025 and acknowledged that no new interventions were put into place for further fall prevention. Record review of a revised care plan that was given to the surveyor by the Administrator upon exit, revealed the fall care plan was revised on 4/16/2025 to include a new intervention for a PT evaluation with an initiation date of 4/7/2025.

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

Resident Rights (Tag F0550)

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 treat each resident with...

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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 treat each resident with respect and dignity in an environment that promotes maintenance of his or her quality of life for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of the facility policy titled, Resident Rights Under Federal Law, states in part, .To promote and protect the rights of the resident .the right to request, refuse, and/or discontinue treatment . Record review of a facility reported incident submitted to the Rhode Island Department of Health on 4/14/2025 indicated that Resident ID #1 reported that s/he was held down by a staff member after refusing medications. The report further alleges that the nurse administered the medications via the resident's gastrostomy (G-Tube- a tube that is surgically inserted through the abdomen and placed directly into the stomach) after s/he had refused the medications multiple times. Record review revealed that the resident was admitted to the facility in April of 2024 with diagnoses including, but not limited to, Cerebral Palsy (a condition that effects muscle movement and posture caused by brain damage most often at birth) and dysarthria (a motor speech disorder). 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 care plan dated 9/17/2024 revealed the resident has impaired communication with interventions including, but not limited to, allowing the resident sufficient time to process and respond. Record review revealed a physician's order dated 1/7/2025 indicating medications may be given by mouth if unable to access the G-Tube. Record review revealed a progress note dated 4/13/2025 indicating that the resident was combative and kicking staff while administering medications. Record review of the April 2025 Medication Administration Record (MAR) revealed the resident was administered the following medications on 4/13/2025 at 6:00 AM: -Diltiazem 60 milligrams (mg) -Eliquis 5 mg -Folic Acid 1 mg -Furosemide 20 mg -Gabapentin 300 mg -Keppra 10 milliliters (ml) -Lactulose 10 grams -Metoprolol Tartrate 50 mg -Senna 8.6 mg -Sertraline 100 mg -150 ml water flush During a surveyor interview on 4/15/2025 at approximately 3:00 PM with the resident, s/he verbally stated that a couple of days ago, staff held his/her arms down and administered medications after s/he said no repeatedly. The resident further stated that s/he did not like that and that the staff should have known better. During a surveyor interview on 4/15/2025 at approximately 3:20 PM with the Nursing Educator, she indicated that the resident is alert and oriented and can make his/her needs known. However, the resident can be difficult to understand. She further indicated that the resident takes his/her medications by mouth and/or via G-Tube. During a surveyor interview on 4/15/2025 at 3:28 PM with Registered Nurse, Staff A, she indicated that she worked 3:00 PM to 11:00 PM on the resident's unit on 4/13/2025 and the Nursing Assistant (NA), Staff B told her that she had held the resident's hands down that morning so the nurse could administer his/her medications. Staff A further indicated that she reported this incident to a supervisor immediately. During a surveyor interview on 4/15/2025 at 3:36 PM with NA, Staff B, she indicated that the resident was kicking and screaming because s/he didn't want to take his/her medications. She further indicated that the nurse asked her to help, so she rubbed the resident's arm and distracted him/her while the nurse administered his/her medications via the G-Tube. Review of the written statement dated 4/15/2025 from Registered Nurse (RN) Staff C, she indicated that the resident was nonverbal and was being combative while she was attempting to administer the resident's medications. The statement further indicated that the resident did not want to take the medications by mouth so she administered them via G-tube. An attempt to interview RN, Staff C, was made on 4/15 and 4/16/2025, however, she was unable to be contacted via telephone. During a surveyor interview on 4/16/2025 at 8:40 AM with the Director of Nursing Services and the Administrator, they indicated that if a resident refuses medication, the nurse should not administer the medication and notify the provider of the refusal. Additionally, they indicated that the resident is able to make his/her needs known and is not usually combative with staff.

Dec 2024 5 deficiencies

CONCERN (D)

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

Deficiency F0806 (Tag F0806)

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 a...

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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 accommodate residents' food preferences for 2 of 5 residents, Resident ID #s 28 and 30. Findings are as follows: Record review of the facility policy titled, Dining and Food Preferences revised on 10/2022, revealed that individual dining, food, and beverage preferences are identified for all residents. The individual tray assembly ticket will identify all food items appropriate for the residents based on diet order and preferences. 1. Record review revealed that Resident ID #28 was admitted to the facility in September of 2021 with a diagnosis including, but is not limited to, anxiety disorder. Record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. During a surveyor interview at the resident council meeting on 12/3/2024 at approximately 1:00 PM with Resident ID #28, s/he revealed that s/he has told the dietary and nursing staff that s/he dislikes eggs and continues to receive them during meals. Record review of Resident ID #28's meal ticket on 12/4/2024 at 8:44 AM, revealed that s/he was not supposed to receive eggs with meals and was supposed to receive pancakes instead. During a surveyor observation of the breakfast meal pass on 12/4/2024 at 8:44 AM, Resident ID #28 was served two boiled eggs and failed to receive pancakes, as preferred. During a surveyor interview on 12/4/2024 at 8:48 AM with Registered Nurse, Staff B, she revealed that the dietary aides set up the individual tray assemblies and was unsure why Resident ID #28 was served eggs and failed to receive pancakes, as preferred and indicated on the resident's meal ticket. 2. Record review revealed that Resident ID #30 was admitted to the facility in March of 2024 with a diagnosis including, but is not limited to, depression. Record review of the Quarterly MDS assessment dated [DATE] revealed a score BIMS of 15 out of 15, indicating intact cognition. Record review of Resident ID #30's meal ticket on 12/2/2024 at 12:25 PM, revealed that s/he ordered a shredded pork sandwich and coleslaw. During a surveyor observation on 12/2/2024 at 12:29 PM, revealed that Resident ID #30 received a turkey patty. During a surveyor interview with the resident following the above observation, s/he revealed that s/he wanted the shredded pork sandwich and coleslaw for lunch but did not receive it and s/he stated that half of the time s/he does not get what s/he has ordered. During a surveyor interview on 12/4/2024 at 1:29 PM with the Regional Executive Chef, he acknowledged that Resident ID #28 failed to receive the meal listed on the meal ticket and would expect the meal tickets to reflect what the residents receive on their individual tray assemblies.

CONCERN (E)

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 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 who require dialysis (a procedure to remove waste products and excess fluids from the blood when the kidneys stop working properly) receive such services, consistent with professional standards of practice for 2 of 2 residents reviewed, Resident ID #s 11 and 32. Findings are as follows: 1. Record review revealed Resident ID #32 was admitted to the facility in September of 2024 with diagnoses including, but not limited to, end stage renal disease and dependence on renal dialysis. Further record review revealed the resident receives outpatient dialysis three times a week on Tuesday, Thursday, and Saturday. Record review revealed the resident has an Arteriovenous Fistula (AVF; a connection between an artery and a vein for dialysis access) to his/her right upper extremity for dialysis treatments. a) Review of the care plan revealed interventions to monitor his/her AVF for bruit (a whooshing sound that is heard through a stethoscope indicating turbulent blood flow in an artery) and thrill (a vibration felt on the skin overlying an area with turbulent blood flow) every shift and as needed. Review of the resident's progress notes from [DATE] to [DATE] revealed that the resident's bruit and thrill were not assessed for 95 out of 96 opportunities. b) Review of the facility's policy titled, Dialysis: Hemodialysis (HD) Provided by a Certified End Stage Renal Disease (ESRD) Facility revealed that the care of the resident receiving HD must reflect ongoing communication, coordination, and collaboration between the nursing facility and the dialysis center staff including advance directives and code status. Review of a MOLST (Medical Orders for Life Sustaining Treatment) form located in Resident ID #32's medical chart dated [DATE] indicated, do not attempt resuscitation (DNR). Review of Resident ID #32's dialysis communication binder revealed a MOLST form dated [DATE] indicated, attempt cardiopulmonary resuscitation (CPR). During a surveyor interview with the Director of Nursing Services (DNS) on [DATE] at 12:26 PM, she acknowledged that the resident was a DNR and the most recent MOLST form, dated [DATE] indicating the updated DNR status, should have been placed in the dialysis communication book. c) According to the National Kidney Foundation .fluid overload in dialysis patients occurs when too much water builds up in the body. It can cause swelling, high blood pressure, breathing problems, and heart issues. Having too much water in your body is called fluid overload or hypervolemia .That's why it's so important to limit how much sodium (salt) and fluid you have between dialysis treatments .Follow the fluid guidelines given to you by your healthcare team. Most dialysis patients need to limit their fluid intake to 32 ounces per day . Record review failed to reveal evidence of a fluid restriction for Resident ID #32 from [DATE] to [DATE]. Further record review revealed during the survey process a fluid restriction order was initiated for Resident ID #32 on [DATE]. During a surveyor interview on [DATE] at 2:20 PM with Registered Nurse, Staff A, she was unable to provide evidence that the facility was monitoring the resident's fluid intake from [DATE] to [DATE]. During a surveyor interview on [DATE] at 2:30 PM with Resident ID #32's Dialysis Clinical Manager, she revealed that she would expect the resident to be on a fluid restriction, as s/he receives dialysis. During a surveyor interview on [DATE] at 2:42 PM with the DNS, she was unable to provide evidence that the facility was monitoring the resident's fluid intake from [DATE] to [DATE], or assessing the AVF for a bruit and thrill. 2. Record review revealed Resident ID #11 was admitted to the facility in January of 2021 with diagnosis including, but is not limited to, chronic kidney disease, stage 4 (kidneys are severely damaged and minimally functioning). Further record review revealed Resident ID #11 receives outpatient dialysis three times a week, on Tuesday, Thursday, and Saturday. Record review revealed a physician's order dated [DATE] for a 1500 mL fluid restriction daily, indicating that the resident should not exceed the following fluid totals in a 24-hour period: -Nursing: 780 mL -Dietary: 720 mL Record review failed to reveal evidence that the facility was monitoring Resident ID #11's total daily fluid intake, until after it was brought to the facility's attention, on [DATE]. During a surveyor observation on [DATE] at 12:13 PM of Resident ID #11, s/he was observed in his/her room with the following fluids at his/her bedside: - 180 mL of apple juice - 180 mL of milk - 480 mL of water Additional observation on [DATE] at 12:23 PM revealed the following fluids served with his/her lunch meal: - 180 mL of ginger ale - 240 mL of coffee Record review failed to reveal evidence that the above fluids were recorded and monitored until it was brought to the facility's attention by the surveyor. During surveyor interviews on [DATE] at 12:31 PM and 12:45 PM with Registered Nurse, Staff B, she acknowledged that Resident ID #11 is on a fluid restriction but failed to provide documentation of his/her total fluid intake, and that it should be monitored. During a surveyor interview on [DATE] at 12:54 PM with the DNS, she was unable to provide evidence that the facility was monitoring Resident ID #11's fluid intake. During a surveyor interview on [DATE] at 1:54 PM with Resident ID #11's Physician, he revealed that he would expect the facility to monitor and document the resident's fluid intake, every shift.

CONCERN (E)

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected multiple residents

Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for a...

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Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for a medication with parameters, Resident ID #23. Findings are as follows: Record review revealed that the resident was readmitted to the facility in July of 2023 with diagnoses including, but not limited to, dementia and hypotension (low blood pressure; blood pressure lower than 90/60). Review of a physician's order dated 9/16/2024 revealed Midodrine 5 milligrams (mg), give one tablet three times daily for hypotension with parameters to hold the medication if the systolic blood pressure (SBP; top number/pressure when the heart beats) is greater than 120. Review of the November and December 2024 Medication Administration Records (MAR) revealed that the resident was administered the Midodrine when the resident's SBP indicated it should be held based on the parameters on the following dates and times: 11/2/2024 - Evening (Blood Pressure (BP) 132/80) 11/3/2024 - Evening (BP 124/80) 11/4/2024 - Evening (BP 122/80) 11/5/2024 - Morning (BP 122/60) Evening (BP 128/78) 11/6/2024 - Evening (BP 142/68) 11/7/2024 - Evening (BP 130/80) 11/8/2024 - Evening (BP 122/64) 11/11/2024 - Evening (BP 132/74) 11/12/2024 - Evening (BP 128/78) 11/14/2024 - Evening (BP 126/70) 11/15/2024 - Afternoon (BP 142/60) 11/16/2024 - Morning (BP 138/78) 11/17/2024 - Evening (BP 128/70) 11/18/2024 - Morning (BP 132/80) Afternoon (BP 132/80) 11/19/2024 - Afternoon (BP 128/62) 11/22/2024 - Evening (BP 122/78) 11/23/2024 - Evening (BP 128/72) 11/24/2024 - Evening (BP 136/76) 11/26/2024 - Evening (BP 161/120) 11/29/2024 - Morning (BP 122/71) Evening (BP 136/76) 12/2/2024 - Evening (BP 122/58) During a surveyor interview on 12/3/2024 at 12:30 PM with Registered Nurse, Staff C, she acknowledged that Midodrine should not have been administered due to the resident's blood pressure being outside of the parameters. During a surveyor interview on 12/3/2024 at 12:42 PM with the Director of Nursing Services, she was unable to provide evidence that the facility's staff followed the physician's order for administering the Midodrine. During a surveyor interview on 12/3/2024 at 1:54 PM via the telephone with the resident's Physician, he revealed that he was unaware that the staff was administering the Midodrine outside of the parameters ordered. Additionally, he revealed that he would expect staff to follow the order as written.

CONCERN (E)

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

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected multiple residents

Based on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include an antibiotic stewardship ...

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Based on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include an antibiotic stewardship program for antibiotic use protocols and a system to monitor antibiotic usage for 2 of 3 residents, Resident ID #s 23 and 27. Findings are as follows: 1. Review of a facility policy titled, Antimicrobial Stewardship Program Long Term Care last reviewed 7/1/2024 refers to the Centers for Disease Control and Prevention (CDC) document titled, The Core Elements of Antibiotic Stewardship for Nursing Homes regarding the facility's antibiotic stewardship procedure. This revealed that all antibiotics prescribed in the facility must be reviewed for the ongoing need for and choice of an antibiotic when the clinical picture is clearer, and more information is available (antibiotic time-out). a) Record review revealed that Resident ID #23 was readmitted to the facility in July of 2023 with diagnoses including, but not limited to, sepsis (blood infection) and urinary tract infection. Record review revealed the resident was started on Amoxicillin (antibiotic) 500 milligrams (mg) for 7 days for the treatment of a urinary tract infection. Record review failed to reveal evidence that an antibiotic time-out was completed following the initiation of the Amoxicillin for Resident ID #23, per the facility's policy. b. Record review revealed that Resident ID #27 was admitted to the facility in August of 2024 with a diagnosis including, but is not limited to, infection of the intervertebral disc (spine). Record review revealed a physician's order for Ciprofloxacin (antibiotic) 500 mg by mouth two times a day for a wound infection with a start date of 10/25/2024 and an end date of 11/22/2024. Record review failed to reveal evidence that an antibiotic time-out was completed following the initiation of the Ciprofloxacin for Resident ID #27, per the facility policy. During a surveyor interview on 12/5/2024 at 10:35 AM with the Director of Nursing Services (DNS), the Infection Preventionist, the Administrator, and the Market Lead Clinical Specialist, they acknowledged that the facility failed to complete antibiotic time-outs for Resident ID #s 23 and 27, per the facility policy. 2. Further record review of the CDC's document titled, The Core Elements of Antibiotic Stewardship for Nursing Homes, recommends that the facility should have a tracking system related to antibiotic use, including days of therapy, to identify opportunities for improvement in determining the appropriateness of antibiotic therapy. Record review of the facility's IPCP failed to reveal evidence of a tracking system of antibiotic use that includes days of therapy. During surveyor interview on 12/4/2024 at 9:03 AM with the Infection Preventionist and the DNS, they revealed that they were unaware of the antibiotic days of therapy, and they do not track them.

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

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standar...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety relative to the main kitchen. Findings are as follows: 1. Record review of the Rhode Island Food Code 2018 Edition 4-601-11 states in part, .Nonfood contact surfaces shall be kept free of an accumulation of dirt, dust, food residue and other debris . Surveyor observations made during the initial tour of the main kitchen on 12/2/2024 at approximately 8:40 AM revealed the following: - the walls in the main kitchen and dish room had an accumulation of black matter - a fan located in the dish room had a significant built up of dust and debris, approximately one inch thick - a floor drain in front of the steamer had a buildup of approximately 1.5 inches of thick, grayish black colored grime. 2. Record review of the State Operations Manual Appendix PP-Guidance to Surveyors for Long term care Facilities 483.60(i)(1)-(2) states in part, .chemical products and supplies, must be clearly marked . Record review of the Occupational Safety and Health Administration Standard 1910.1200 (f)(1) states in part, .chemicals are marked with a product identifier, signal word (danger or warning), a statement that the full label information for the chemical is provided on the outside package . During a surveyor observation of the main kitchen on 12/2/2024 at approximately 8:40 AM, revealed a spray cleaning bottle with a pink colored substance which failed to have a label that included a signal word or a statement that the full label information for the chemical. During a surveyor interview on 12/5/2024 at approximately 11:11 AM with the Regional Executive Chef, he acknowledged that the walls, ceiling fan, and the floor drain needed to be cleaned. Additionally, he acknowledged that the spray cleaning bottle failed to have the appropriate labeling.

May 2024 12 deficiencies 3 IJ (2 affecting multiple)

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 protect the...

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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 protect the resident's right to be free from abuse for 1 of 1 resident observed for abuse, Resident ID #2. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 4/26/2024 revealed that Nursing Assistant (NA), Staff B, reported an allegation of abuse that occurred on 4/24/2024 between Resident ID #2 and two staff members, NA, Staff D and Certified Medication Technician (CMT), Staff E. Staff B indicated that she overheard a resident yelling out loudly followed by a bang noise around 9:30 PM. Review of a facility policy titled Abuse Prohibition Policy and Procedure states in part, .prohibits abuse, mistreatment, neglect .for all residents. This includes, but is not limited to, freedom from corporal punishment .any physical or chemical restraint not required to treat the patient's medical symptoms. Centers also strive to comply with the Elder Justice Act (EJA). Under the EJA, employees are designated as mandated reporters and are obligated to immediately report any suspicion of a crime against a resident .Physical Abuse includes hitting, slapping, pinching, kicking, etc., as well as controlling behavior through corporal punishment . Record review revealed Resident ID #2 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, dementia and cognitive communication deficit. Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (an assessment used to determine cognition) was unable to be completed due to the resident being rarely/never understood, indicating that s/he is severely cognitively impaired. During a surveyor interview on 5/2/2024 at 12:37 PM, with the Administrator and Director of Nursing Services (DNS), they revealed that they were made aware of the allegation of abuse on 4/26/2024, when NA, Staff B asked another staff member about the incident. They indicated that they watched the video footage from 4/24/2024 around 9:30 PM, and observed NA, Staff D and CMT, Staff E physically abuse and restrain Resident ID #2, while the resident was sitting in a recliner and then a wheelchair, located in the day room of the unit. During a surveyor interview on 5/2/2024 at 1:25 PM, with NA, Staff B and NA, Staff C, translated by the Director Human Resources, Staff L, they revealed that on 4/24/2024 at approximately 9:30 PM, they were assisting other residents in their rooms when they both heard a female resident yelling followed by a loud bang noise coming from the day room. Staff B, revealed that she immediately went to the day room and saw NA, Staff D and CMT, Staff E standing next to Resident ID #2, while s/he was sitting in his/her recliner chair. They revealed that Staff D then took Resident ID #2 out of the day room and assisted him/her in the bathroom and then returned the resident to the day room in a wheelchair. They indicated that when Staff D brought the resident back to the day room, they observed Staff D and E push a table up against the resident, while s/he was sitting in a wheelchair, with his/her back against the wall. A surveyor observation on 5/2/2024 at 1:51 PM, of video footage from 4/24/2024 at 9:49 PM, in the presence of the Administrator and the Human Resource Director, Staff L, revealed Resident ID #2 was seated upright in a recliner chair and was observed attempting to get out of the recliner by placing his/her legs on a table, which was located directly next to the resident. Without notice, NA, Staff D, aggressively stands up and steps towards Resident ID #2 and without hesitation, Staff D uses her right arm to forcefully shove Resident ID #2 on his/her right shoulder, sending him/her backwards abruptly. Staff D then grabbed Resident ID #2's legs and yanked them to the left, continuing to push his/her legs down in an aggressive manner. Staff D was then assisted by CMT, Staff E, who was observed grabbing Resident ID #2 under his/her armpits and lifting his/her body upwards in the chair. At 9:51 PM Staff D was observed pushing the resident out of the dayroom in his/her recliner chair. At 9:58 PM Staff D pushes Resident ID #2 back into the dayroom, in a wheelchair. Resident ID #2 is holding his/her chest area as s/he reenters the room and Staff D places the resident with his/her back against the wall. Staff D aggressively grabs both of Resident ID #2's arms and holds them up so that Staff E can push a table against Resident ID #2's chest. At this time, Staff D was noted to push the table again, causing the table to be wedged between the resident and a support column. During a surveyor interview on 5/2/2024 at approximately 2:15 PM, with NA, Staff D, she revealed that she made a mistake and acknowledged pushing Resident ID #2 on 4/24/2024 and stated that it was not her intention to harm the resident. She further indicated that Licensed Practical Nurse, Staff A, tells staff to keep Resident ID #2 in the day room, restrained in his/her recliner, because the resident is a fall risk due to him/her attempting to get up and walk independently. A surveyor observation of Resident ID #2 on 5/2/2024 at approximately 2:20 PM, in the presence of LPN, Staff J, revealed s/he had scattered bruising noted to both arms. During a surveyor interview on 5/3/2024 at 9:22 AM with CMT, Staff E, he revealed that on 4/24/2024, Staff D called him over to assist her, after she brought the resident back to the dayroom. He acknowledged that he pulled the table close to the resident, indicating that Staff A has previously told staff to place the resident in this position, due to him/her being at risk for falls. During a surveyor interview on 5/3/2024 at 9:46 AM, with LPN, Staff A, she revealed that nothing out of the ordinary occurred on 4/24/2024 and indicated that she did not witness any incidents of abuse. She indicated that she has never facilitated staff to restrain the resident in the dayroom but acknowledged that she has allowed it to happen before due to a safety concern as staff do not properly monitor the residents especially when they are on their phones. Record review revealed a skin assessment dated [DATE] at 10:56 PM, which revealed the resident had bruises because arms restlessness, and legs throws them over recliner. Record review revealed a skin assessment dated [DATE] which revealed the resident was noted to have several pea size to pinpoint bruises on his/her right and left lower arms, nickel size bruises on his/her forearms, pea size bruises on his/her wrists and hands, two small bruises on his/her right upper arm, and a bruise noted to the lower front of his/her leg. During a surveyor interview on 5/2/2024 at 11:58 AM and 5/3/2024 at 2:00 PM, with the Administrator and DNS, they revealed that NA, Staff D was terminated following this incident and CMT, Staff E was suspended due to the incident. Additionally, they were unable to provide evidence that Resident ID #2 was kept free from physical abuse.

CRITICAL (K) 📢 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

Deficiency F0604 (Tag F0604)

Someone could have died · This affected multiple 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 res...

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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 residents have the right to be free from any physical restraint, not required to treat the resident's medical symptoms, for 2 of 3 residents reviewed, Resident ID #s 2 and 7. Findings are as follows: Review of a facility policy titled, .Restraints: Use of states in part, .Patients have the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the patient's medical symptoms .Convenience is defined as the result of any action that has the effect of altering a patient's behavior such that the patient requires a lesser amount of effort or care, and is not in the patient's best interest .Physical Restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: Is attached or adjacent to the patient's body, Cannot be removed easily by the patient, and Restricts the patient's freedom of movement or normal access to their body .Patients will be evaluated for the use of restraints or protective devices during the nursing assessment process .If the device cannot be easily removed by the patient and/or restricts freedom of movement or normal access to their body, the Restraint Evaluation/Reduction will be completed .There must be documentation identifying the medical symptom being treated and an order for the use of the specific type of restraint .Consent must be obtained prior to the application of the restraint. The patient, or patient representative if applicable, has the right to refuse the use of a restraint and may withdraw consent to use the restraint at anytime. Refusal must be documented in the medical record . Review of a facility reported incident submitted to the Rhode Island Department of Health on 4/26/2024 revealed that Nursing Assistant (NA), Staff B reported an allegation of abuse that occurred on 4/24/2024 between Resident ID #2 and two staff members, NA, Staff D and Certified Medication Technician (CMT), Staff E. Staff B indicated that she overheard a resident yelling out loudly followed by a bang noise around 9:30 PM. A surveyor observation on 5/2/2024 at 1:51 PM, of video footage from 4/24/2024 at 9:49 PM, in the presence of the Administrator and the Human Resource Director, Staff L, revealed Resident ID #2 was seated upright in a recliner chair, with the wall on his/her left side and a table on his/her right side. Additionally, a chair was placed in front of Resident ID #2's elevated footrest, preventing the footrest of the recliner from releasing. Resident ID #7 was noted to be lying in a recliner, up against the back of Resident ID #2's recliner chair. Therefore, Resident ID #2 could not safely get out of the recliner if s/he wanted to, as there was a wall on his/her left side, a table on his/her right side, a chair under his/her footrest, and another resident, Resident ID #7, directly behind him/her, sitting in a recliner. Additionally, Resident ID #7 could not safely get out of the recliner if s/he wanted to, as the resident was reclined back and would be unable to reach the foot lever, as it is located behind the recliner. Additional surveyor observation of the video footage from 4/24/2024 at 9:51 PM, revealed that NA, Staff D was observed pushing the resident out of the room in his/her recliner chair. At 9:58 PM Staff D pushes Resident ID #2 back into the dayroom, in a wheelchair. Resident ID #2 is holding his/her chest area as s/he reenters the room and Staff D places the resident with his/her back against the wall. Staff D aggressively grabs both of Resident ID #2's arms and holds them up so that CMT, Staff E can push a table against Resident ID #2's chest. At this time, Staff D was noted to push the table again, causing the table to be wedged between the resident and a support column. Staff D then pulled Resident ID #7's recliner, towards Resident ID #2's wheelchair, so the footrest of Resident ID #7's recliner was propped up on Resident ID #2's wheelchair, preventing the recliner from returning to an upright position, not allowing Resident ID #7 to get up independently. 1. Record review revealed Resident ID #2 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, dementia and cognitive communication deficit. Review of a Minimum Data Set Assessment (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS, an assessment used to determine cognition) was unable to be completed due to the resident being rarely/never understood, indicating that s/he is severely cognitively impaired. Further review revealed the resident utilizes a wheelchair for mobility and requires extensive assistance for transfers by staff members. Record review failed to reveal evidence of any restraint assessments, consent form, physician orders, or care plan interventions, prior the incident on 4/24/2024, per the Restraints: Use of policy. During a surveyor interview with Licensed Practical Nurse (LPN), Staff J, on 5/2/2024 at 2:20 PM, she revealed the resident can stand up and walk but his/her gait is not steady. She further revealed that the resident can self-propel while in his/her wheelchair by moving his/her legs and feet. During a surveyor interview with LPN, Staff F, on 5/6/2024 at 9:30 AM, she revealed that Resident ID #2 can get up from his/her bed or his/her wheelchair if s/he wants to. Staff F further revealed that the resident can walk but only few steps without staff assistance and the resident will fall without staff assistance. Additionally, Staff F revealed that if the resident is in a recliner chair, s/he will try to get out of it. A surveyor observation of Resident ID #2, in the presence of Staff F on 5/6/2024 at 9:54 AM, revealed the resident was sitting in his/her wheelchair in the day room, with the left wheel in the locked position. It was noted at this time that the resident was trying to self-propel the wheelchair by using his/her feet. Staff F acknowledged that the resident's wheelchair was locked and revealed that the resident can self-propel by moving her/his feet while in his/her wheelchair if the wheelchair was not locked. During a surveyor interview with a NA, Staff H, on 5/6/2024 at 9:58 AM, she revealed that she has been providing care to Resident ID #2 since s/he was admitted to the facility. Staff H then revealed the resident can get up from his/her bed, his/her wheelchair, and his/her recliner chair. Staff H further revealed that the resident can walk but his/her gait is not steady, indicating that s/he can walk approximately 50 feet with assistance from staff. 2. Record review revealed Resident ID #7 was admitted to the facility in February of 2024 with diagnoses including, but not limited to, dementia and cerebral infarction (stroke). Review of a MDS assessment dated [DATE] revealed a BIMS Assessment was unable to be completed due to the resident being rarely/never understood, indicating that s/he is severely cognitively impaired. Further review revealed the resident requires partial/moderate assistance with transfers. During a surveyor interview on 5/6/2024 at 9:40 AM, with LPN, Staff F, she revealed that Resident ID #7 can ambulate a few steps and indicated that at times, the resident tries to get up independently from the wheelchair or recliner chair. During a surveyor interview on 5/6/2024 at 10:06 AM, with NA, Staff G, she revealed that the resident can stand up on his/her own and can ambulate a few steps. Record review failed to reveal evidence of any restraint assessments, consent forms, physician orders, or care plan interventions prior to the incident on 4/24/2024, per the Restraints: Use of policy. During a surveyor interview on 5/2/2024 at 12:37 PM, with the Administrator and Director of Nursing Services (DNS), they acknowledged that Resident ID #2 was being physically restrained on 4/24/2024, by NA, Staff D and CMT, E. They acknowledged that s/he was unable to get up from the recliner chair. They further revealed that during the investigation of this incident, numerous staff have revealed that Resident ID #2 and #7 are often restrained in this manner, due to the residents being at risk for falls. They indicated that LPN, Staff A, told administration that she did, at times, have Nursing Assistants restrain residents in the day room by placing the resident in a recliner chair sideways against the wall, with a table adjacent to the resident on the other side, a chair at the foot of the recliner, as well as another resident behind them. During a surveyor interview on 5/2/2024 at 2:15 PM, with NA, Staff D, she revealed that Resident ID #2 is usually kept in the dining room, restrained in his/her recliner chair, due to resident being at risk for falls, because s/he tries to stand up and ambulate independently. She indicated that Staff A and other nurses have told staff to restrain the residents in this manner due to safety concerns. During a surveyor interview on 5/3/2024 at 9:22 AM with CMT, Staff E, he revealed that on 4/24/2024, Staff D called him over to assist her, after she brought Resident ID #2 back to the dayroom. He acknowledged that he pulled the table close to the resident, restraining him/her in the wheelchair, indicating that Staff A has previously told staff to place the resident in this position, due to him/her being at risk for falls. During a surveyor interview on 5/3/2024 at 9:46 AM, with LPN, Staff A, she indicated that she has never facilitated staff to restrain the resident in the dayroom but acknowledged that she has allowed it to happen in the past, because of a safety concern, indicating that staff do not properly monitor the residents especially when they are on their phones. Further, she revealed that she was unaware that restraining residents in this manner was a concern. During a surveyor interview on 5/2/2024 at 11:58 AM and 5/3/2024 at 2:00 PM, with the Administrator, and the DNS, they revealed that NA, Staff D was terminated following this incident and CMT, Staff E was suspended due to this incident. Additionally, they were unable to provide evidence that Resident ID #2 and #7 were kept free from physical restraints.

CRITICAL (K) 📢 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

Investigate Abuse (Tag F0610)

Someone could have died · This affected multiple 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 provide evid...

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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 evidence that all alleged violations of abuse are thoroughly investigated and reported to the State Survey Agency (Department of Health) for Resident ID #1 and failed to prevent further potential abuse while an investigation was in progress for Resident ID #2. Findings are as follows: Review of a facility policy and procedure revised on 10/24/2022 titled Abuse Prohibition states in part, .6. Staff will identify events .patterns, and trends that may constitute abuse . 6.1 Anyone who witnesses an incident of suspected abuse, neglect .is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately, regardless of shift worked. 6.1.1. The notified supervisor will report the suspected abuse immediately to the Administrator or designee and other officials in accordance with state law. 6.1.2. The employee alleged to have committed the act of abuse will be immediately remove from duty, pending investigation. 6.1.3. All reports of suspected abuse must also be reported to the patient's family and attending physician . 6.2. Anyone who witnesses an incident of suspected abuse, neglect .must also report to outside agencies, if required. 6.2.1 Staff are obligated to report reasonable suspicion of crime against the elderly to the state agency and local law enforcement . 1. Review of a facility reported incident submitted to the Rhode Island Department of Health on 5/2/2024 revealed an allegation of abuse that occurred on 4/24/2024 during the second shift (3:00 PM-11:00 PM), before dinner, involving Resident ID #1, Nursing Assistant (NA), Staff D and Certified Medicaiton Technician (CMT), Staff E. The resident was overheard screaming help me, don't hit me, stop hitting me, you're not my mom. Record review revealed Resident ID #1 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, dementia and anxiety disorder. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS, an assessment used to determine cognition) score of 4 out of 15, indicating s/he is severely cognitively impaired. During a surveyor interview on 5/2/2024 at 1:25 PM, with NA, Staff B and NA, Staff C, translated by the Director of Human Resources, Staff L, they revealed that on 4/24/2024, before dinner time, Staff B overheard Resident ID #1 screaming out loud in his/her room stating, help me, don't hit me, stop hitting me, you're not my mom, while Staff D and Staff E were present in the resident's room. Both Staff B and Staff C revealed that they immediately informed Licensed Practical Nurse (LPN), Staff A, of the abuse concerns with Resident ID #1. Record review failed to reveal evidence that this allegation of abuse involving Resident ID #1 was acted upon immediately. This failure allowed the two perpetrators, NA, Staff D and CMT, Staff E, to continue working the evening of 4/24/2024. Further record review failed to reveal evidence that this allegation of abuse was reported to the Administrator by LPN, Staff A, as required. Additionally, record review failed to reveal evidence of an investigation for this abuse allegation, until 5/1/2024, 7 days after the allegation occurred. This facility failure allowed NA, Staff D and CMT, Staff E, to continue working the evening of 4/24/2024 resulting in another abuse allegation approximately 5 hours later with Resident ID #2. This allegation of abuse was later corroborated by via footage. 2. Review of a facility reported incident submitted to the Rhode Island Department of Health on 4/26/2024 revealed an allegation of abuse that occurred on 4/24/2024 with Resident ID #2 and two staff members, NA, Staff D and CMT, Staff E. Record review revealed Resident ID #2 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, dementia and cognitive communication deficit. Review of a MDS assessment dated [DATE] revealed a BIMS Assessment was unable to be completed due to the resident being rarely/never understood, indicating that s/he is severely cognitively impaired. During a surveyor interview on 5/2/2024 at 12:37 PM, with the Administrator and Director of Nursing Services (DNS), they revealed that they were made aware of the allegation of abuse on 4/26/2024, when NA, Staff B asked another staff member about the incident. They indicated that they watched the video footage from 4/24/2024 around 9:30 PM and observed NA, Staff D and CMT, Staff E, physically abuse and restrain Resident ID #2, while the resident was sitting in a recliner and then wheelchair, located in the day room of the unit. Additionally, the Administrator revealed that they were not aware of the allegation of abuse relative to Resident ID #1 with Staff D and E, that occurred on 4/24/2024 until 5/1/2024, 7 days after the allegation was made. During a surveyor interview on 5/2/2024 at 1:25 PM, with NA, Staff B and NA, Staff C, translated by the Director Human Resources, Staff L, they revealed that on 4/24/2024 at approximately 9:30 PM, they were assisting other residents in their rooms when they both heard a female resident yelling followed by a loud bang noise coming from the day room. Staff B revealed that she immediately went to the day room and saw NA, Staff D and CMT, Staff E standing next to Resident ID #2, while s/he was sitting in his/her recliner chair. They revealed that Staff D then took Resident ID #2 out of the day room and assisted him/her in the bathroom and then returned the resident to the day room in a wheelchair. They indicated that when Staff D brought the resident back to the day room, they observed Staff D holding the resident's hands, while Staff E pushed a table up against the resident, while s/he was sitting in a wheelchair, with his/her back against the wall. Further, both NA's, Staff B and C revealed that they did not report this incident with Resident ID #2 to LPN, Staff A, because they had already reported an allegation of abuse earlier in the shift concerning Resident ID #1. After they informed Staff A of the alleged incident with Resident ID #1, Staff A threw her hands in the air and shrugged her shoulders. During a surveyor interview on 5/3/2024 at 9:46 AM, with LPN, Staff A, she revealed that nothing out of the ordinary occurred on 4/24/2024 and indicated that she did not witness any incidents of abuse. She further revealed that no one reported any allegations of abuse to her throughout the shift on 4/24/2024. She denied that NA's, Staff B and C reported an allegation of abuse to her concerning Resident ID #1. During a surveyor interview on 5/2/2024 at 11:58 AM and 5/3/2024 at 2:00 PM, with the Administrator and the DNS, they were unable to provide evidence that the allegation of abuse for Resident ID #1 was investigated immediately after the allegation was reported to LPN, Staff A, which could have prevented the incident of abuse from occurring with Resident ID #2, if Na, Staff D and CMT, Staff E were removed from duty immediately.

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 observation, record review, and staff interview, it has been determined that the facility failed to treat each...

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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 treat each resident with respect and dignity in a manner and in an environment that promotes maintenance of his or her quality of life, for 2 of 2 residents reviewed, Resident ID #s 2 and 7. Findings are as follows: 1. Review of a facility reported incident submitted to the Rhode Island Department of Health on 4/26/2024 revealed that a Nursing Assistant (NA), Staff B, reported an allegation of abuse that occurred on 4/24/2024 involving Resident ID #2. During a surveyor observation of video footage from 4/24/2024 at 9:48 PM, revealed the resident was seated upright in a recliner chair, with the wall on his/her left side and a table on his/her right side. Additionally, a chair was placed in front of the elevated footrest, preventing the footrest of the recliner from releasing and another resident (Resident ID #7) was noted to be lying in a recliner behind Resident ID #2's recliner chair. Additional, review of the video footage from 4/24/2024 at 9:48 PM, revealed Resident ID #2 was lying in a recliner chair in the day room, wearing only a hospital gown. Subsequently, Resident ID #2 was taken out of the day room and into the hallway by NA, Staff D, where it was noted that the resident's upper thighs and legs were not covered, exposing his/her thighs and legs, while in the recliner chair. The video footage failed to reveal that Staff D attempted to cover the resident's thighs and legs while transporting her/him in the recliner chair. Furthermore, during the review of the video footage from 4/24/2024 at 9:58 PM, revealed Staff D transporting Resident ID #2 back into the day room, in a wheelchair. Staff D aggressively grabs both of Resident ID #2's arms and holds them up so that Certified Medication Technician, Staff E, can push a table against Resident ID #2's chest. At this time, Staff D was noted to push the table again, causing the table to be wedged between the resident and a support column. Record review revealed Resident ID #2 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, dementia and cognitive communication deficit. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS, an assessment used to determine cognition) was unable to be completed due to the resident being rarely/never understood, indicating that s/he is severely cognitively impaired. A surveyor observation on 5/2/2024 at 2:15 PM, revealed the resident was sitting in his/her wheelchair in the day room. The surveyor attempted to interview the resident at the time of this observation, but the resident was unable to answer any questions due to severe cognitive impairment. 2. During an additional observation of the video footage from 4/24/2024 at approximately 9:30 PM through 10:30 PM, it was revealed that Resident ID #7 was noted to be laying in a recliner chair in the day room (behind Resident ID #2's recliner chair). Throughout this time, it was noted that Resident ID #7 appeared to be in and out of sleep, with his/her head hanging over the side of the recliner chair. Record review revealed Resident ID #7 was readmitted to the facility in February of 2024 with diagnoses including, but not limited to, dementia, cerebral infarction (stroke) and agitation. Review of an admission MDS assessment dated [DATE] revealed a BIMS Assessment was unable to be completed due to the resident being rarely/never understood, indicating that s/he is severely cognitively impaired. A surveyor observation on 5/2/2024 at 2:05 PM revealed the resident was lying in his/her recliner chair in the day room. The surveyor attempted to interview the resident at the time of the observation, but the resident was unable to answer any questions due to his/her severe cognitive impairment. During a surveyor interview with Licensed Practical Nurse, Staff A, on 5/3/2024 at 9:46 AM, she revealed that she works full time on the secured memory care unit on the 3:00 PM through 11:00 PM shift. She further revealed that Resident ID #'s 2 and 7 have dementia and all their needs must be anticipated by staff. She indicated that they are kept in the unit's day room during her shift for safety reasons as staff do not properly monitor the residents especially when they are on their phones. During a surveyor interview with NA, Staff I, on 5/3/2024 at 12:45 PM, he revealed that he works full time on the memory care unit, on the 11:00 PM to 7:00 AM shift. Staff I further revealed that when he comes into work at 11:00 PM, he usually finds Residents ID #s 2 and 7 lying in their recliner chairs in the day room. During a surveyor interview with NA, Staff K on 5/3/2024 at 12:56 PM, he revealed he works full time on the memory care unit, on the 3:00 PM to 11:00 PM shift. Staff K further revealed that when he comes into work at 3:00 PM, he usually finds Residents ID #s 2 and 7 lying in their recliner chairs in the day room, and indicated that they remain there until 11:00 PM, when he leaves. During a surveyor interview with the Administrator and the Director of Nursing Services on 5/3/2024 at 3:20 PM, they acknowledged the facility failed to treat Residents ID #s 2 and 7 in a dignified manner and in an environment that promotes maintenance of their quality of life.

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 F0726 (Tag F0726)

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 ensure that nursing staff have the appropriate skill sets to provide nursing and r...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being of each resident, as determined by resident assessments and individual plans of care, relative to restraints, for 5 of 7 staff reviewed, Staff D, E, G, H, and I. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 4/26/2024 revealed an allegation of abuse that occurred on 4/24/2024 with Resident ID #2 and two staff members, Nursing Assistant (NA), Staff D and Certified Medication Technician (CMT), Staff E. A surveyor observation on 5/2/2024 at 1:51 PM, of video footage from 4/24/2024 at 9:49 PM, in the presence of the Administrator and the Human Resource Director, Staff L, revealed Resident ID #2 was seated upright in a recliner chair, with the wall on his/her left side and a table on his/her right side. Additionally, a chair was placed in front of Resident ID #2's elevated footrest, preventing the footrest of the recliner from releasing. Resident ID #7 was noted to be lying in a recliner, up against the back of Resident ID #2's recliner chair. Therefore, Resident ID #2 could not safely get out of the recliner if s/he wanted to, as there was a wall on his/her left side, a table on his/her right side, a chair under his/her footrest, and another resident, Resident ID #7, directly behind him/her, sitting in a recliner. Additionally, Resident ID #7 could not safely get out of the recliner if s/he wanted to, as the resident was reclined back and would be unable to reach the foot lever, as it is located behind the recliner. An additional surveyor observation of the video footage from 4/24/2024 at 9:51 PM, revealed that NA, Staff D was observed pushing the resident out of the room in his/her recliner chair. At 9:58 PM Staff D pushes Resident ID #2 back into the dayroom, in a wheelchair. Resident ID #2 is holding his/her chest area as s/he reenters the room and Staff D places the resident with his/her back against the wall. Staff D aggressively grabs both of Resident ID #2's arms and holds them up so that CMT, Staff E can push a table against Resident ID #2's chest. At this time, Staff D was noted to push the table again, causing the table to be wedged between the resident and a support column. Staff D then pulled Resident ID #7's recliner, towards Resident ID #2's wheelchair, so the footrest of Resident ID #7's recliner was propped up on Resident ID #2's wheelchair, preventing the recliner from returning to an upright position, not allowing Resident ID #7 to get up independently. During a surveyor interview on 5/2/2024 at 12:37 PM, with the Administrator and the Director of Nursing Services (DNS), they acknowledged that Resident ID #2 was being physically restrained on 4/24/2024, by Staff D and E. They acknowledged that s/he was unable to get up from the recliner chair. They further revealed that during the investigation of this incident, numerous staff have revealed that Resident ID #2 and #7 are often restrained in this manner, due to the residents being at risk for falls. They indicated that Licensed Practical Nurse, Staff A, told administration that she did, at times, have Nursing Assistants restrain residents in the day room by placing the resident in a recliner sideways against the wall, with a table adjacent to the resident on the other side, a chair at the foot of the recliner, as well as another resident behind them. Review of the facility assessment, last revised 1/19/2024 revealed the facility provides education on physical restraints. Review of a document titled, 2023 Mandatory Annual Training Quarterly Crosswalk revealed an education topic titled Restraint and Seclusion, to be completed by staff in quarter 4 of 2023. Record review failed to reveal evidence that the following staff completed the mandatory restraint and seclusion education in 2023: - NA, Staff D, hired on 9/22/2009 - CMT, Staff E, hired on 8/18/2009 - NA, Staff G, hired on 6/12/2022 - NA, Staff H, hired on 10/6/2016 - NA, Staff I, hired on 6/10/2016 During a surveyor interview on 5/6/2024 at 2:03 PM, with the Regional Nurse, in the presence of the Administrator and the DNS, they were unable to provide evidence that the restraint and seclusion training was completed for the above-mentioned staff. Cross reference F 604

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected multiple residents

Based on record review and staff interview, it has been determined the pharmacist failed to report irregularities to the attending physician, the facility's Medical Director, and the Director of Nursi...

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Based on record review and staff interview, it has been determined the pharmacist failed to report irregularities to the attending physician, the facility's Medical Director, and the Director of Nursing Services (DNS) for 1 of 3 residents reviewed for monthly drug regimen reviews, Resident ID #8. Findings are as follows: Record review revealed the resident was admitted to the facility in January of 2021 with diagnoses including, but not limited to, dementia, anxiety, and depression disorder. Record review revealed the resident has a physician's order dated 12/1/2023 for Lorazepam (a medication used to treat anxiety disorders or for serious seizures that do not stop) Oral Concentrate 2 milligrams (MG)/milliliter (ML), with instructions to give 1 ML by mouth every 24 hours as needed for a seizure lasting more than 5 minutes. Further review of the order failed to reveal evidence of an end date or a documented rationale for extending the duration of use for this as needed medication. Record review of the May 2024 Medication Administration Record revealed that the resident received the above-mentioned medication one time at 1:53 PM on 5/1/2024 and was noted to have a good effect. Review of the Pharmacist Consultation Recommendation Reports for the following dates failed to reveal evidence that the pharmacist identified that the above order did not have an end date: - 12/13/2023 - 1/8/2024 - 2/5/2024 - 3/5/2024 - 4/28/2024 During a surveyor interview with the Pharmacist on 5/7/2024 at 9:45 AM, he revealed that he completed the consultation reports for 3/5/2024 and 4/28/2024. The Pharmacist was unable to provide evidence that the above irregularity was reported to the attending physician, the facility's Medical Director, and the DNS as required.

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

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary psychotropic drugs who have as needed psychotro...

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Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary psychotropic drugs who have as needed psychotropic medication orders extending beyond 14 days, for 1 of 3 residents reviewed for unnecessary medication, Resident ID #8. Findings are as follows: Record review revealed the resident was admitted to the facility in January of 2021 with diagnoses including, but not limited to, dementia, anxiety and depression disorder. Record review revealed the resident has a physician's order dated 12/1/2023 for Lorazepam (a medication used to treat anxiety disorders or for serious seizures that do not stop) Oral Concentrate 2 milligrams (MG)/milliliter (ML), with instructions to give 1 ML by mouth every 24 hours as needed for a seizure lasting more than 5 minutes. Further review of the order failed to reveal evidence of an end date or a documented rationale for extending the duration of use for this as needed medication. Record review of the May 2024 Administration Record revealed that the resident received the above-mentioned medication one time at 1:53 PM on 5/1/2024, and it was noted to have a good effect. During a surveyor interview with Licensed Practical Nurse, Staff F, on 5/6/2024 at 1:25 PM, she revealed that the resident does not have a diagnosis of a seizure disorder and/or any history of seizure activity. Staff F further revealed that she administered the medication to the resident on 5/1/2024 because the resident was scratching his/her arms. During a surveyor interview with the Director of Nursing Services on 5/6/2024 at 1:30 PM, she acknowledged that the above order has no end date and that the resident received the medication for a purpose it was not ordered for.

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 F0941 (Tag F0941)

Could have caused harm · This affected multiple residents

Based on record review and staff interview, it has been determined that the facility failed to ensure that all direct care staff completed mandatory effective communication training, for 5 out of 7 st...

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Based on record review and staff interview, it has been determined that the facility failed to ensure that all direct care staff completed mandatory effective communication training, for 5 out of 7 staff reviewed, Staff D, E, G, H, and I. Findings are as follows: Record review failed to reveal evidence that the following staff completed the mandatory effective communication training or education for 2023: - NA, Staff D, hired on 9/22/2009 - Certified Medication Technician, Staff E, hired on 8/18/2009 - NA, Staff G, hired on 6/12/2022 - NA, Staff H, hired on 10/6/2016 - NA, Staff I, hired on 6/10/2016 During a surveyor interview on 5/6/2024 at 2:03 PM, with the Regional Nurse, in the presence of the Administrator and Director of Nursing Services, they were unable to provide evidence that the training was completed for the above-mentioned staff.

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 F0944 (Tag F0944)

Could have caused harm · This affected multiple residents

Based on record review and staff interview, it has been determined that the facility failed to provide mandatory training to all their staff, that outlines and informs staff of the elements and goals ...

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Based on record review and staff interview, it has been determined that the facility failed to provide mandatory training to all their staff, that outlines and informs staff of the elements and goals of the facility's QAPI (Quality Assurance and Performance Improvement) program, for 5 out of 7 staff reviewed, Staff D, E, G, H, and I. Findings are as follows: Record review failed to reveal evidence that the following staff completed QAPI training or education for 2023: - NA, Staff D, hired on 9/22/2009 - Certified Medication Technician, Staff E, hired on 8/18/2009 - NA, Staff G, hired on 6/12/2022 - NA, Staff H, hired on 10/6/2016 - NA, Staff I, hired on 6/10/2016 During a surveyor interview on 5/6/2024 at 2:03 PM, with the Regional Nurse, in the presence of the Administrator and Director of Nursing Services, they were unable to provide evidence that the training was completed for the above-mentioned staff.

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 F0946 (Tag F0946)

Could have caused harm · This affected multiple residents

Based on record review and staff interview, it has been determined that the facility failed to provide mandatory training to all their staff, that outlines compliance and ethics, including an effectiv...

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Based on record review and staff interview, it has been determined that the facility failed to provide mandatory training to all their staff, that outlines compliance and ethics, including an effective way to communicate the program's standards, policies, and procedures, for 5 out of 7 staff reviewed, Staff D, E, G, H, and I. Findings are as follows: Record review failed to reveal evidence that the following staff completed training or education on compliance and ethics for 2023: - NA, Staff D, hired on 9/22/2009 - Certified Medication Technician, Staff E, hired on 8/18/2009 - NA, Staff G, hired on 6/12/2022 - NA, Staff H, hired on 10/6/2016 - NA, Staff I, hired on 6/10/2016 During a surveyor interview on 5/6/2024 at 2:03 PM, with the Regional Nurse, in the presence of the Administrator and Director of Nursing Services, they were unable to provide evidence that the training was completed for the above-mentioned staff.

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 F0949 (Tag F0949)

Could have caused harm · This affected multiple residents

Based on record review and staff interview, it has been determined that the facility failed to provide all staff with behavioral health training, for 5 out of 7 staff reviewed, Staff D, E, G, H, and I...

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Based on record review and staff interview, it has been determined that the facility failed to provide all staff with behavioral health training, for 5 out of 7 staff reviewed, Staff D, E, G, H, and I. Findings are as follows: Record review failed to reveal evidence that the following staff completed the mandatory behavioral health training or education for 2023: - NA, Staff D, hired on 9/22/2009 - Certified Medication Technician, Staff E, hired on 8/18/2009 - NA, Staff G, hired on 6/12/2022 - NA, Staff H, hired on 10/6/2016 - NA, Staff I, hired on 6/10/2016 During a surveyor interview on 5/6/2024 at 2:03 PM, with the Regional Nurse, in the presence of the Administrator and Director of Nursing Services, they were unable to provide evidence that the training was completed for the above-mentioned staff.

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

QAPI Program (Tag F0867)

Could have caused harm · This affected most or all residents

Based on record review and staff interview it has been determined that the facility's Quality Assessment and Assurance Improvement (QAPI) committee failed to develop and implement appropriate plans of...

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Based on record review and staff interview it has been determined that the facility's Quality Assessment and Assurance Improvement (QAPI) committee failed to develop and implement appropriate plans of action to correct the identified quality deficiencies relative to resident abuse and resident rights. Findings are as follows: Record review revealed the facility received a pattern of deficiencies relative to resident abuse and resident rights on the following dates: - 1/24/2024: F 600 for the failure to protect a resident from abuse by a staff member (a housekeeper was observed kissing a resident) and F 609 for the failure to report an allegation of abuse in a timely manner, as required by state law. -2/19/2024 F 600 for the failure to protect a resident's right to be free from abuse by a staff member, relative to staff not providing incontinence care. Record review revealed that the facility provided education to only nursing staff relative to resident abuse and resident rights on 3/4/2024 and audited incontinence care. Further record review failed to reveal evidence that the facility had developed a plan to include monitoring and evaluation of performance indicators, including the methodology and frequency for such development and monitoring, and evaluating the plan to determine if they are sustaining corrections, or if revision is necessary. Review of a facility reported incident submitted to the Rhode Island Department of Health on 4/26/2024 revealed that Nursing Assistant (NA), Staff B, reported an allegation of abuse that occurred on 4/24/2024 between Resident ID #2 and two staff members, NA, Staff D and Certified Medication Technician (CMT), Staff E. Staff B indicated that she overheard a resident yelling out loudly followed by a bang noise around 9:30 PM. Additionally, review of a facility reported incident submitted to the Rhode Island Department of Health on 5/2/2024 revealed an allegation of abuse that occurred on 4/24/2024 during the second shift (3:00 PM-11:00 PM), before dinner, involving Resident ID #1, Staff D and Staff E. The resident was overheard screaming help me, don't hit me, stop hitting me, you're not my mom. Record review failed to reveal evidence that the allegation involving Resident ID #1 was acted upon immediately. This failure allowed the NA, Staff D and CMT, E to continue working on the evening of 4/24/2024. During a surveyor interview with the Administrator and the Director of Nursing Services (DNS) on 5/2/2024 at 12:37 PM, they revealed that since they learned about the two allegations of abuse that had occurred on 4/24/2024, they have provided education relative to abuse and restraints to nursing staff only. The Administrator and the DNS were unable to provide evidence that the facility has developed a QAPI plan to include monitoring and evaluation of performance indicators, including the methodology and frequency for such development and monitoring, and evaluating the plan to determine if they are sustaining corrections, or if revision is necessary. During the survey, findings which constituted Immediate Jeopardies were identified as the facility failed to keep residents free from physical abuse, failed to keep residents free from physical restraints, and failed to report an allegation of abuse to the Administrator or his or her designated representative, investigate an allegation of abuse, and implement a plan to prevent further incidents of abuse from occurring. Cross reference F 550, F 600, F 604 and F 610.

Feb 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

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 protect the residents' right to be free from neglect for 1 of 3 residents reviewed relative to incontinen...

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Based on record review and staff interview, it has been determined that the facility failed to protect the residents' right to be free from neglect for 1 of 3 residents reviewed relative to incontinence care, Resident ID #2. Findings are as follows: Record review revealed the resident was readmitted to the facility in October of 2021 with diagnoses including but not limited to, dementia, major depressive disorder, and constipation. Record review of the care plan initiated on 11/25/2019 indicates the resident requires assistance for activities of daily living. Further review revealed a care plan initiated on 2/24/2023 which indicates the resident is incontinent of bowels. The goal indicates that s/he will have incontinence care needs met by the staff to maintain his/her dignity and comfort. During surveyor observations on 2/19/2024 revealed the following: - 9:22 AM the resident was observed in the dining room participating in a group activity when s/he abruptly stopped participating in the activity and yelled out bowel movement, bowel movement, bowel movement. - 9:32 AM the Nursing Assistant (NA), Staff A, along with the assistance of another NA brought the resident back to his/her room and transferred the resident via Hoyer lift (mechanical lift) to his/her bed. The staff members did not offer to toilet the resident or check to see if s/he had a bowel movement. - 9:32 AM to 10:56 AM- No staff members entered the resident's room - 10:57 AM the surveyor went in the resident's room, s/he was observed lying in bed on his/her left side, awake, looking at the wall. There was a strong odor of feces noted. An interview was attempted with the resident, but s/he was unable to answer the surveyor's questions due to his/her diagnoses of dementia. During a surveyor interview on 2/19/2024 at 11:38 AM with Staff A, he revealed that he put the resident back to bed because when s/he yells out bowel movement and this is his/her cue that s/he has to move his/her bowels. When the surveyor asked Staff A if he checked the resident for incontinence after putting him/her to bed, he stated he will change him/her before bringing him/her to the dining room for lunch. When the surveyor revealed the resident's room had a strong odor of feces Staff A again indicated that he will toilet him/her before lunch. During a surveyor observation on 2/19/2024 at 11:52 AM, Staff A was observed with NA, Staff B changing the resident's brief (adult diaper). Staff A acknowledged that the resident needed to be changed as his/her brief was observed to be soiled with feces and urine. During a surveyor interview on 2/19/2024 at 1:21 PM with the Director of Nursing Services in the presence of the Regional Clinical Lead, she stated that she would expect the resident to be provided with incontinence care soon after s/he was yelled out bowel movement. Additionally, she indicated that they should not have waited until lunchtime to provide the resident with incontinence care. Furthermore, she was unable to provide evidence that Resident ID #2 was kept free from neglect.

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

Free from Abuse/Neglect (Tag F0600)

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 pr...

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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 protect the resident's right to be free from staff to resident abuse for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 1/17/2024 revealed that on 1/4/2024 a facility contracted staff member, Housekeeper, Staff B, was observed passionately kissing Resident ID #1 in his/her room. Review of a facility policy titled Abuse Prohibition states in part, .the center will implement abuse prohibition program through the following .protect of patients during investigations; and reporting of incidents, investigations, and the center response to the result of their investigations .5. Actions to prevent abuse, neglect, exploitation, or mistreatment .will include .evaluating whether the patient has capacity to consent to sexual activity . Review of the resident's record revealed s/he was admitted to the facility in August of 2023 with a diagnosis to include but is not limited to dementia. Record review of a Brief Interview for Mental Status assessment dated [DATE] revealed a score of 12 out of 15 indicating moderately impaired cognition. Record review revealed staff witness statements from an Occupational Therapist, Staff A, a Physical Therapist, Staff C, a Physical Therapy Assistant, Staff D, and a Speech Therapist, Staff E all dated 1/4/2024, which indicated that Staff B was observed in Resident #1's room sitting on his/her bed kissing him/her on the lips several times lasting up two minutes. Record review of Staff D's statement revealed that Staff B and Resident ID #1 were in an extended lip lock . Record review of an undated witness statement authored by the alleged perpetrator, Staff B, indicated, that she went into Resident ID #1's room and they engaged in tongue kissing a few times. Record review of an email exchange dated 1/16/2024 at 11:54 AM between the facility's Social Worker, Staff F and Resident ID # 1's daughter states in part .here are the screen shots I notified you about on 1/8 when it was brought to my attention. You told me you would inform administration but clearly that did not happen. I am disgusted to hear that this [staff member was allowed to keep [his/her] job after almost a month of having an inappropriate relationship with my [family member] who is clearly disabled physically but also mentally. I called to speak with the admin [facility administrator] this morning at 9:15, left a message and heard nothing back. This is elderly abuse . Record review of the alleged perpetrator, Staff B's employee file and simultaneous interview with Account Manager, Staff G, revealed that Staff B was hired by the facility on 6/17/2004 and was converted to a contracted staff member on 11/17/2013. Lastly, she was unable to provide evidence that a background check was completed for Staff B. During a surveyor interview on 1/24/2024 with Staff B, she revealed that on 1/4/2024 she visited Resident ID #1 because .[s/he] threatened to disown me . She indicated that during the interaction with the resident they kissed, and she placed her hands on his/her genitals. During a surveyor interview on 1/24/2024 with Resident ID #1 s/he stated in part, .[Staff B] is a facility worker .was a little more than that to me .we seen each other every day she begged me to kiss .loved the way I kissed .she wanted a ring I told [Staff B] I'd get it from the ground .maybe she preys on older [gender] .I gave her $50.00 for Christmas . During a surveyor interview with the Administrator on 1/24/2024 at 4:29 PM, she acknowledged that Staff B, was witnessed kissing Resident ID #1 on 1/4/2024. Further, she could not provide evidence that a BCI was completed for Staff B. Lastly, she was unable to provide evidence that Resident ID #1 was kept free from resident abuse.

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on record review, resident and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than...

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Based on record review, resident and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made to the State Agency in accordance with State law for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Review of a facility policy titled Abuse Prohibition states in part, .all reports of suspected abuse must be reported .Report allegations to appropriate state and local authority(s) .within 24 hours if the event does not result in serious bodily injury . Record review of a facility reported incident submitted to the Rhode Island Department of Health on 1/17/2024 revealed that on 1/4/2024 a facility contracted staff member, Housekeeper, Staff B, was observed passionately kissing Resident ID #1 in his/her room. Additional record review revealed that on 1/4/2024 four staff members informed the facility that they witnessed Staff B kissing Resident ID #1 in his/her room on 1/4/2024. Further review revealed that the initial report was submitted on 1/17/2024 which was thirteen days after the incident occurred. During a surveyor interview on 1/24/2024 with Staff B, she revealed that on 1/4/2024 she visited Resident ID #1 because .[s/he] threatened to disown me . She indicated that during the interaction with the resident they kissed and she placed her hands on his/her genitals. During a surveyor interview on 1/24/2024 with Resident ID #1 s/he stated in part, .[Staff B] is a facility worker .was a little more than that to me .we seen each other every day she begged me to kiss .loved the way I kissed .she wanted a ring I told [Staff B] I'd get it from the ground .maybe she preys on older [gender] .I gave her $50.00 for Christmas . During a surveyor interview with the Administrator on 1/24/2024 at 3:11 PM, she acknowledged the above-mentioned allegation occurred. Additionally, she was unable to provide evidence as to why the incident was not reported until 1/17/2024, thirteen days after the incident occurred. Refer to F 600

Jan 2024 3 deficiencies 2 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 F0658 (Tag F0658)

A resident was harmed · 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 tre...

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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 assessing for injury after a fall, for 1 of 1 resident reviewed, Resident ID #2. Findings are as follows: Record review of a facility policy dated 8/7/2023 titled, Falls Management, revealed the following in part, .Post-Fall Management .Evaluate the patient for injury .Notify the physician/advanced practice provider (APP) of the fall, report physical findings and extent of injuries, and obtain orders if indicated . According to the August 2021, American Association of Post-Acute Care Nursing, online publication titled, POST-FALL ASSESSMENTS, which states in part, .Fall-related injuries are common, so it is important that nurses be able to conduct a post-fall assessment to determine if injuries are present and treat accordingly .it is an assessment of the resident to determine if an injury has occurred and whether action is needed to stabilize the resident medically .The most common fall-related injuries sustained by a .resident include .Musculoskeletal injuries, such as hip fracture or muscle tear .Skin and deeper-tissue trauma, such as bruises, abrasions, skin tears .When assessing the resident for post-fall injuries .always be aware of the resident's verbal and non-verbal expression of pain. The following changes post-fall indicate an injury has occurred .Vital signs .changes from the resident's normal baseline could also indicate an injury .Range of motion to a joint - The resident's ability to move a joint freely has been compromised, or the joint is hyperextended .Skin integrity - The resident's skin is bruised, discolored, swollen, or open from a fracture .Assess for a hip fracture by comparing the lower extremities to each other. If there is a hip fracture, the involved extremity will be shorter than the extremity and externally rotated . Record review of a facility reported incident submitted to the Rhode Island Department of Health (RIDOH) on 1/10/2024, alleges that while the Licensed Practical Nurse (LPN), Staff A, was escorting the resident in the hallway in a wheelchair, his/her foot dropped, causing him/her to lean forward. Additionally, the report alleges that Staff A held the resident by his/her jacket, lowered him/her to the floor then assisted him/her back into the wheelchair. Furthermore, the report states in part, .Resident has baseline pain in left leg. Oxycodone [narcotic pain medication] .was already given prior to incident for transport. Resident doesn't use foot rests as [s/he] self propels ad lib [as desired]. Resident denied any increase pain or tenderness . Review of a community reported complaint submitted to RIDOH on 1/10/2024 alleges that the resident arrived at the Emergency Department on 1/9/2024 after falling from his/her wheelchair earlier in the morning. The report further indicates that the resident is wheelchair bound and was sitting in the wheelchair with his/her legs crossed when the staff member moved the wheelchair, resident's left leg got stuck in the wheels causing him/her to fall out of the wheelchair. Lastly, the report indicates s/he was admitted to the hospital due to a fracture of his/her left leg. Record review revealed that the resident was readmitted to the facility in December of 2023, with diagnoses including, but not limited to, dementia, left knee effusion (water on the knee that causes pain), and end stage renal (kidney) disease, on hemodialysis HD- a treatment to filter wastes and water from blood when the kidneys are unhealthy. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 11 out of 15, indicating moderately impaired cognition. Additionally, the MDS revealed that s/he has impaired range of motion on one side of his/her lower extremity and requires the use of a wheelchair. Review of a progress note dated 1/9/2024 revealed documentation of a change in condition evaluation due to the resident's fall. The note indicates pain was the outcome of the physical assessment. Review of a written statement authored by Staff A dated 1/15/2024 indicated that he assessed the resident for increased pain and assisted him/her to put back on his/her slipper. The note failed to reveal evidence the resident was assessed for injury including range of motion, physical injury and vital signs. During a surveyor observation of the facility's surveillance camera footage dated 1/9/2024 at approximately 5:26 AM, in the presence of the Director of Nursing Services, on 1/16/2024 at 10:54 AM, revealed the following. The footage revealed Staff A, assisting Resident ID #2 with transport while in his/her wheelchair in the corridor outside of the resident's room without the use of foot pedals. Staff A was observed to hold on to the resident's coat as s/he was leaning forward in the wheelchair. Staff A was observed to turn the wheelchair around and transported the resident down the remainder of the corridor with the wheelchair in reverse. Additionally, the observation failed to reveal evidence that Staff A assessed Resident ID #2 for injury including range of motion, physical injury and vital signs after s/he fell from his/her wheelchair. Record review of the 1/9/2024 dialysis encounter nursing progress note revealed that Resident ID #2 complained of pain upon arrival to the clinic when staff attempted to assist with raising his/her legs. The dialysis nurse assessed him/her and noted a small bruise on the resident's right foot along with a superficial skin tear to his/her right ankle. The note further indicates that the resident was moaning and groaning .Patient stated 'the transporter rolled over my foot' .'this morning at the nursing home.' The note further indicates that Resident ID #2 was restless and once the blanket on his/her lap was removed, staff noted large bruising .about 8 inches in diameter and was elevated about 5 inches on the patient's Left upper thigh approximately 5 inches below the hip bone .the patients left knee was facing medially [toward the center of the body] .The left leg was also shorter than the right leg . Furthermore, the note indicates that the dialysis nurse contacted the facility and spoke with the nurse in charge.[Resident ID #2] came into the unit and is complaining of foot pain .The LPN stated '[S/he] is talking about me. [Resident ID#2] usually self propels in [his/her] wheelchair so [s/he] did not have foot petals [SIC] on the wheelchair while I was transporting [him/her] to meet [his/her] driver to be transported to dialysis. At first all I noticed was [s/he] was falling forward so I grabbed [his/her] coat and pulled [him/her] back. Then the patient said 'oww that hurt' .when I assessed the patient it turns out [s/he] had not held [his/her] feet up during transport like usual and [his/her] foot got caught under the front wheel of the wheelchair. I took off [his/her] slipper and sock and [s/he] didn't appear to have sustained any injuries so I continued to transport [him/her] to the transportation provider . Additional record review revealed that the resident was transferred from the dialysis center to the hospital due to complaints of severe pain and was subsequently admitted to an acute care hospital with the diagnosis of left femur (thigh bone) fracture. Further record review failed to reveal evidence that Staff A thoroughly assessed Resident ID #2 for injuries, which would include, but not limited to, assessing his/her vital signs, extremities for range of motion, and skin for injuries, after s/he fell from his/her wheelchair on the morning of 1/9/2024. Additionally, the record failed to reveal evidence that the physician or APP were notified of the fall prior to the resident being transported to his/her routine dialysis appointment. During a surveyor interview with the Director of Nursing Services (DNS) on 1/16/2024 at 2:32 PM, she revealed that she would have expected the nurse to have assessed the resident for injury and document the findings in his/her medical record. During a surveyor interview on 1/17/2024 at 10:57 AM, with the Regional Clinical Nurse in the presence of the DNS, he acknowledged that Staff A failed to thoroughly assess Resident ID #2 after he transported him/her in his/her wheelchair without the use of foot pedals. The resident was then transported to his/her routine dialysis appointment, where his/her injuries were assessed upon arrival, and s/he was subsequently admitted to the hospital due to a left femur fracture.

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

Accident Prevention (Tag F0689)

A resident was harmed · 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 a re...

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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 a resident's environment remains as free of accident hazards and provide assistive devices to prevent an avoidable accident for 1 of 1 resident reviewed who sustained major injuries after falling from his/her wheelchair, while being assisted by a staff member without the use of foot pedals, Resident ID #2. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health (RIDOH) on 1/10/2024, alleges that while the Licensed Practical Nurse (LPN) Staff A, was escorting the resident in the hallway in a wheelchair, his/her foot dropped, causing him/her to lean forward. Additionally, the report alleges that Staff A held the resident by his/her jacket, lowered him/her to the floor then assisted him/her back into the wheelchair. Furthermore, the report states in part, .Resident has baseline pain in left leg. Oxycodone [narcotic pain medication] .was already given prior to incident for transport. Resident doesn't use foot rests as [s/he] self propels ad lib [as desired]. Resident denied any increase pain or tenderness . Review of a community reported complaint submitted to RIDOH on 1/10/2024 alleges that the resident arrived at the Emergency Department on 1/9/2024 after falling from his/her wheelchair earlier in the morning. The report further indicates that the resident is wheelchair bound and was sitting in the wheelchair with his/her legs crossed when the staff member moved the wheelchair, resident's left leg got stuck in the wheels causing him/her to fall out of the wheelchair. Lastly, the report indicates s/he was admitted to the hospital due to a fracture of his/her left leg. Record review of a facility policy dated 8/7/2023 titled, Falls Management, revealed the following in part, .Patients experiencing a fall will receive appropriate care and post-fall interventions will be implemented .PURPOSE .To evaluate the patient for injury post-fall and provide appropriate and timely care .5. Post-Fall Management .Evaluate the patient for injury .Notify the physician/advanced practice provider (APP) of the fall, report physical findings and extent of injuries, and obtain orders if indicated .Document circumstances of the fall, post-fall assessment, and patient outcome . Record review revealed that the resident was readmitted to the facility in December of 2023, with diagnoses including, but not limited to, dementia, left knee effusion (water on the knee that causes pain), and end stage renal (kidney) disease, on hemodialysis (HD- a treatment to filter wastes and water from blood when the kidneys are unhealthy). Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 11 out of 15, indicating moderately impaired cognition. Additionally, the MDS revealed that s/he has impaired range of motion on one side of his/her lower extremity and requires the use of a wheelchair. Record review revealed a physician's order dated 10/24/2023 for non-weight bearing to the left leg every shift. Additional record review revealed a physician's order dated 11/10/2023 indicating the resident is transported out of the facility for Dialysis every Tuesday, Thursday, and Saturday at 5:45 AM. Review of a progress note dated 1/9/2024 revealed documentation of a change in condition evaluation due to the resident's fall. The note indicates pain was the outcome of the physical assessment. Review of a written statement authored by Staff A dated 1/15/2024 indicated that he assessed the resident for increased pain and assisted him/her to put back on his/her slipper. The note failed to reveal evidence the resident was assessed for injury including range of motion, physical injury and vital signs. During a surveyor observation of the facility's surveillance camera footage dated 1/9/2024 at approximately 5:26 AM, in the presence of the Director of Nursing Services, on 1/16/2024 at 10:54 AM, revealed the following. The footage revealed Staff A, assisting Resident ID #2 with transport while in his/her wheelchair in the corridor outside of the resident's room without the use of foot pedals. Staff A was observed to hold on to the resident's coat as s/he was leaning forward in the wheelchair. Staff A was observed to turn the wheelchair around and transported the resident down the remainder of the corridor with the wheelchair in reverse. Additionally, the observation failed to reveal evidence that Staff A assessed Resident ID #2 for injury including range of motion, physical injury and vital signs after s/he fell from his/her wheelchair. During a surveyor interview on 1/12/2024 at 2:27 PM, with LPN, Staff A, he revealed that on 1/9/2024 at 5:30 AM he was taking the resident to the front door to leave for his/her appointment because s/he was running late. Staff A further indicated that he brought the resident down the hallway while s/he was sitting in his/her wheelchair. He indicated that the resident self-propels usually and does not use foot pedals on the wheelchair. While transporting the resident s/he put his/her foot down and fell forward. Staff A indicated he grabbed the resident by his/her coat and lowered him/her to the floor. He further indicated that he assumed that the resident had his/her feet up. Furthermore, Staff A indicated that the resident complained of left leg pain and indicated that s/he always has pain. S/he was able to get back up with staff assistance and was transported to his/her appointment. The dialysis center called the facility to report Resident ID #2 had complaints of increased pain upon his/her arrival to the clinic, and was transferred to an acute care hospital for an evaluation via rescue. A surveyor interview on 1/12/2024 at 2:46 PM was attempted with the nurse from the dialysis center, which was unsuccessful. Record review of the 1/9/2024 dialysis encounter nursing progress note revealed that Resident ID #2 complained of pain upon arrival to the clinic when staff attempted to assist with raising his/her legs. The dialysis nurse assessed him/her and noted a small bruise on the resident's right foot along with a superficial skin tear to his/her right ankle. The note further indicates that the resident was moaning and groaning .Patient stated 'the transporter rolled over my foot' .'this morning at the nursing home.' The note further indicates that Resident ID #2 was restless and once the blanket on his/her lap was removed, staff noted large bruising .about 8 inches in diameter and was elevated about 5 inches on the patient's Left upper thigh approximately 5 inches below the hip bone .the patients left knee was facing medially [toward the center of the body] .The left leg was also shorter than the right leg . Furthermore, the note indicates that the dialysis nurse contacted the facility and spoke with the nurse in charge.[Resident ID #2] came into the unit and is complaining of foot pain .The LPN stated '[S/he] is talking about me. [Resident ID#2] usually self propels in [his/her] wheelchair so [s/he] did not have foot petals [SIC] on the wheelchair while I was transporting [him/her] to meet [his/her] driver to be transported to dialysis. At first all I noticed was [s/he] was falling forward so I grabbed [his/her] coat and pulled [him/her] back. Then the patient said 'oww that hurt' .when I assessed the patient it turns out [s/he] had not held [his/her] feet up during transport like usual and [his/her] foot got caught under the front wheel of the wheelchair. I took off [his/her] slipper and sock and [s/he] didn't appear to have sustained any injuries so I continued to transport [him/her] to the transportation provider . Further record review revealed the resident was transferred from the dialysis center to an acute care hospital and admitted with a diagnosis of left femur (thigh bone) fracture. Record review of the hospital documents revealed the following entries: 1/9/2024 at 7:11 AM, which states in part, .Pt [patient] was being pushed in wheelchair, leg got stuck underneath wheelchair and wheelchair kept going. Pt still brought to dialysis, dialysis was not done d/t [due to] injury to leg. 1/9/2024 at 10:17 AM titled, ED [Emergency Department] Provider Note, revealed in part, .comes in due to left leg pain. Patient reports that earlier this morning [s/he] had his legs crossed in [his/her] wheelchair, and [his/her] left leg got stuck on the wheels when they started pushing [him/her]. [S/he] reports falling over and possibly hitting [his/her] head .was brought in by EMS [Emergency Medical Services] due to left leg pain. [S/he] currently has associated neck pain . 1/9/2024 at 7:26 PM, titled ED Provider Note which states in part, .PMH [past medical history] of .prior left knee replacement, presents with left thigh pain and swelling s/p [status post] trauma while in a wheelchair .Left thigh swelling and left lower extremity deformity significantly internally rotated .Imaging reveals a periprosthetic mid femur fracture [a broken bone around or close to an implant] with significant angulation .Plan pain control, orthopedic consult .Patient requires admission orthopedics .recommending above knee amputation . During a surveyor interview on 1/16/2024 at approximately 12:15 PM, with the Registered Occupational Therapist (OTR), Staff B and Physical Therapist Assistant (PTA), Staff C, they revealed that foot pedals should be placed on a wheelchair if a resident is unable to keep his/her feet up when sitting in the wheelchair and receiving locomotion assistance from a staff member. They also indicated that Resident ID #2 did not have foot pedals for his/her wheelchair because s/he can independently propel him/herself. During a surveyor interview on 1/16/2024, at 10:54 AM with the Director of Nursing Services (DNS), she acknowledged that the resident does not have foot pedals for his/her wheelchair because s/he is independent with self-propelling. She indicated that Staff A was unable to locate foot pedals after the incident, so he continued to transport the resident to the lobby for transport with the wheelchair in reverse. Additionally, she indicated that upon his/her return from the hospital, foot pedals will be provided for use when s/he goes to dialysis. Furthermore, the DNS was unable to provide evidence that Staff A kept Resident ID #2 free from accident hazards which resulted in him/her falling from the wheelchair, experiencing pain, was unable to complete dialysis treatment, and being admitted to the hospital due to significant injuries.

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

Notification of Changes (Tag F0580)

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 immediately consult with the resident's physician when there is an accident involv...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to immediately consult with the resident's physician when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention, for 1 of 1 resident reviewed for falls, Resident ID #2. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health (RIDOH) on 1/10/2024, alleges that while the Licensed Practical Nurse (LPN) Staff A, was escorting the resident in the hallway in a wheelchair, his/her foot dropped, causing him/her to lean forward. Additionally, the report alleges that Staff A held the resident by his/her jacket, lowered him/her to the floor then assisted him/her back into the wheelchair. Furthermore, the report states in part, .Resident has baseline pain in left leg. Oxycodone [narcotic pain medication] .was already given prior to incident for transport. Resident doesn't use foot rests as [s/he] self propels ad lib [as desired]. Resident denied any increase pain or tenderness . Review of a community reported complaint submitted to RIDOH on 1/10/2024 alleges that the resident arrived at the Emergency Department on 1/9/2024 after falling from his/her wheelchair earlier in the morning. The report further indicates that the resident is wheelchair bound and was sitting in the wheelchair with his/her legs crossed when the staff member moved the wheelchair, resident's left leg got stuck in the wheels causing him/her to fall out of the wheelchair. Lastly, the report indicates s/he was admitted to the hospital due to a fracture of his/her left leg. Record review of a facility policy dated 8/7/2023 titled, Falls Management, revealed the following in part, .Notify the physician/advanced practice provider (APP) of the fall, report physical findings and extent of injuries, and obtain orders if indicated . Record review revealed that the resident was readmitted to the facility in December of 2023, with diagnoses including, but not limited to, dementia, left knee effusion (water on the knee that causes pain), and end stage renal (kidney) disease, on hemodialysis (HD- a treatment to filter wastes and water from blood when the kidneys are unhealthy). Review of a progress note dated 1/9/2024 at 5:30 AM revealed documentation of a change in condition evaluation due to the resident's fall. The note indicates pain was the outcome of the physical assessment. Additional record review revealed a progress note dated 1/9/2024 at 1:03 PM, authored by the unit manager, which indicates she notified the Nurse Practitioner (NP) of the resident's accident which occurred on the morning of 1/9/2024. Further record review failed to reveal evidence that the physician or NP were notified and immediately consulted regarding the resident's accident on the morning of 1/9/2024. During a surveyor telephone interview on 1/17/2024 at 10:38 AM, with the resident's medical doctor (MD), he revealed that he could not recall being notified and immediately consulted regarding the resident's accident on the morning of 1/9/2024. Additionally, he was unable to provide evidence that the NP was notified immediately and consulted regarding the resident's accident prior to him/her being transported to dialysis and subsequently being admitted to the hospital with a diagnosis of a left femur fracture. During a surveyor interview on 1/17/2024 at 10:48 AM, with the Unit Manager, she revealed that she authored the above-mentioned progress note dated 1/9/2023 at 1:03 PM. Additionally, she acknowledged that she notified the Nurse Practitioner of Resident ID #2's accident from his/her wheelchair after s/he had left the facility for dialysis and was subsequently admitted to the hospital with the diagnosis of a left femur fracture. During a surveyor interview on 1/17/2024 at 11:31 AM with the Director of Nursing Services, she was unable to provide evidence that the MD or NP were notified and immediately consulted after the resident's accident when s/he fell from his/her wheelchair while being assisted with transport by Staff A without the use of foot pedals, which resulted in the resident being admitted to the hospital with a diagnosis of a left femur fracture.

Dec 2023 7 deficiencies

CONCERN (D)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

**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 maintain a safe, clean, co...

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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 maintain a safe, clean, comfortable, and homelike environment relative to 1 of 3 units, the [NAME] unit. Findings are as follows: During a surveyor observation on 12/18/2023 at 9:30 AM on the [NAME] Unit, room [ROOM NUMBER], revealed an extension cord attached to the air conditioner that was connected to the wall socket next to the sink. Further observation revealed linens and a pillow that were on top of the extension cord. During a subsequent surveyor observation on 12/18/2023 at 10:20 AM on the [NAME] unit revealed ceiling paint that was peeling in the common bathroom, approximately 2 feet by 2 feet. During a subsequent surveyor observation and interview to room [ROOM NUMBER], and to the common bathroom on the [NAME] unit on 12/20/2023 at 8:30 AM, in the presence of the Maintenance Director, Regional Maintenance Director, and the Interim Administrator, they acknowledged the above findings and were unable to provide evidence that the facility maintained a safe, clean, and comfortable homelike environment.

CONCERN (D)

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

Deficiency F0655 (Tag F0655)

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 develop and implement a baseline care plan for each resident within 48 hours of a r...

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Based on surveyor observation, record review and staff interview, it has been determined that 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 the resident that meets professional standards of quality care relative to MRSA (methicillin-resistant Staphylococcus aureus - a bacteria that does not get better with the type of antibiotics that usually cure staph infections) in a vascular wound (wounds on your skin that develop because of problems with blood circulation) and a condom catheter (a urine collection device), for 1 of 2 residents reviewed for baseline care plans, Resident ID #235. Findings are as follows: Record review revealed that the resident was admitted to the facility in December of 2023 with diagnoses including, but not limited to, benign prostatic hyperplasia (prostate gland enlargement that can cause urination difficulty) and urinary tract infection. A. During a surveyor observation on 12/18/2023 at 10:40 AM outside of the resident's room revealed a cart of personal protective equipment, masks, gloves, etc. Review of a progress note dated 12/19/2023 revealed the resident has MRSA in his/her foot wound. Record review of the baseline care plan initiated on 12/19/2023 failed to reveal evidence of a care plan that includes interventions or treatments for MRSA. B. Review of a Integrated Wound Care document dated 12/19/2023 revealed the resident has vascular wounds to bilateral toes 2-4. Record review of the baseline care plan initiated on 12/19/2023 failed to reveal evidence of a baseline care plan that includes interventions or treatments for bilateral vascular wounds. C. Record review revealed a physician's order for a condom catheter. Record review of the resident's baseline care plan initiated on 12/19/2023 failed to reveal evidence of a baseline care plan that includes interventions or treatments for a condom catheter. During a surveyor interview on 12/21/2023 at approximately 11:00 AM with the Director of Nursing Services (DNS), she acknowledged that the resident has orders for MRSA, vascular wounds, and a condom catheter. Additionally, she acknowledged that none of the above-mentioned concerns were part of the resident's baseline care plan. The DNS failed to reveal evidence that a baseline care plan was implemented within 48 hours of the resident's admission, that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care.

CONCERN (E)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple 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 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 each resident receives the necessary care and services to maintain the highest practicable physical well-being for 3 of 7 residents observed on the dementia unit, Resident ID #s 35, 43, and 61. Findings are as follows: Review of a facility policy titled, Activities of Daily Living [ADL] dated 5/1/2023, states in part, .Purpose to ensure ADLs are provided in accordance with accepted standards of practice, the care plan, and the patient's choices and preferences . Review of a policy titled, Continence Management dated 6/15/2022, states in part, Practice Standards .Provide routine incontinence care . 1. Record review revealed that Resident ID #43 was admitted to the facility in June of 2023 with diagnoses including, but limited to, dementia and muscle weakness. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating severe cognitive impairment. Additional review of the MDS revealed the resident is always incontinent of bowel and bladder. Review of a care plan initiated on 6/22/2023 revealed the resident is at risk for skin breakdown due to incontinence. During a surveyor observation on 12/18/2023 from 9:13 AM until 1:18 PM revealed the resident remaining in the dining room without being offered to utilize the toilet or being provided with incontinence care, a total time of 4 hours and 5 minutes. Throughout continuous surveyor observation the resident was observed standing, yelling help, and banging his/her hands on the table. Additionally, the staff on the unit was observed to repeatedly tell him/her to sit down. During a surveyor observation on 12/18/2023 at 12:20 PM, the resident was yelling in the dining room that s/he wanted to go to the bathroom. There was no staff observed in the room at the time. During a surveyor observation on 12/19/2023 from 8:13 AM until 1:01 PM revealed the resident remaining in the dining room without being offered to utilize the toilet or being provided with incontinence care, a total time of 4 hours and 48 minutes. Throughout the continuous surveyor observation the resident was observed standing repeatedly and asking staff for help. During a surveyor observation on 12/19/2023 at 1:04 PM with Certified Nursing Assistant (CNA), Staff B, while taking Resident ID #43 to the bathroom, s/he was observed with an incontinence brief with a pull up on the outside (double briefed). The incontinence brief was noted to be saturated with urine. During a surveyor interview immediately following the above observation with Staff B she acknowledged that the resident had a brief and a pull up on. Additionally, she revealed that an incontinent resident should be toileted or offered incontinence care approximately every 2 hours. She also indicated that a resident should not be double briefed. 2. Record review revealed that Resident ID #35 was readmitted to the facility in October of 2021 with diagnoses including, but not limited to, dementia and muscle weakness. Review of an MDS assessment dated [DATE] revealed a BIMS score of 4 out of 15 indicating severe cognitive impairment. Further review of the MDS revealed s/he is always incontinent of bowel and bladder. Review of a care plan initiated on 11/18/2020 revealed the resident is incontinent of urine and is at risk for skin breakdown. During a surveyor observation on 12/18/2023 from 9:13 AM until 1:18 PM revealed the resident remaining in the dining room without being offered to utilize the toilet or being provided with incontinence care, a total time of 4 hours and 5 minutes. During a surveyor observation on 12/19/2023 from 8:13 AM until 1:01 PM revealed the resident remaining in the dining room without being offered to utilize the toilet or being provided with incontinence care, a total time of 4 hours and 48 minutes. 3. Record review revealed that Resident ID #61 was admitted to the facility in January of 2021 with diagnoses including, but not limited to, dementia and muscle weakness. Review of an MDS assessment dated [DATE] revealed a BIMS score of 2 out of 15 indicating severe cognitive impairment. Additional review revealed s/he is always incontinent of bowel and bladder. Review of a care plan initiated 1/26/2023 revealed the resident is incontinent of bowel and bladder and is at risk for skin breakdown due to immobility. During a surveyor observation on 12/18/2023 from 9:13 AM until 1:18 PM revealed the resident remaining in the dining room without being offered to utilize the toilet or being provided with incontinence care, a total time of 4 hours and 5 minutes. During a surveyor observation on 12/19/2023 from 8:13 AM until 1:01 PM revealed the resident remaining in the dining room without being offered to utilize the toilet or being provided with incontinence care, a total time of 4 hours and 48 minutes. During a surveyor observation on 12/19/2023 at 1:17 PM of incontinence care for Resident ID #61 in the presence of CNA, Staff C and Registered Nurse (RN), Staff D, s/he had been incontinent of both urine and feces in his/her incontinence brief. During a surveyor interview directly following the above observation with Staff D, she revealed an incontinent resident should be provided incontinence care every 2 hours but not to exceed 3 hours. Additionally, she revealed that she was unaware that Resident ID #61 was in the dining room for approximately 5 hours without being provided care. During a surveyor interview on 12/19/2023 at 2:41 PM with the Director of Nursing Services (DNS) and the Regional Clinical Nurse, they were unable to provide evidence that each resident was provided incontinence care to maintain the highest practicable physical well-being. Additionally, the DNS and Regional Nurse were unable to state what an appropriate amount of time a resident should be provided incontinence care and indicated that if a resident does not have skin breakdown or an infection that it would be okay for a resident to not be toileted or provided incontinence care for up to 6 hours.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure that medication bottles were dated and discarded per the manufacturer's instructions when e...

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Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure that medication bottles were dated and discarded per the manufacturer's instructions when expired in 2 of 3 medication carts and 2 of 3 medication rooms observed, and that the refrigerator in 1 of 3 medication rooms observed was kept clean. Findings are as follows: 1. During a surveyor observation on 12/20/2023 at 8:34 AM following the medication administration task on the [NAME] Unit, the following medications were found to be expired and undated: - 2 bottles of natural tear drops were opened and undated - 1 bottle of Fish oil expired 9/2023 - 1 bottle of Mucinex 400 milligram (mg) expired 11/2023 - 1 bottle of Oyster shell expired 11/2023 - 1 pack of loperamide hydrochloride tablet 2 mg expired 11/2023 2. During an observation on 12/20/2023 at approximately 9:00 AM of the medication room on [NAME] Unit, the following medications were observed to be expired: - 1 bottle of vitamin D expired 11/2023 - 1 bottle of Mucinex expired 11/2023 During a surveyor interview on 12/20/2023 following the observation with Registered Nurse, Staff A, she acknowledged that the above-mentioned medications were expired and should have been discarded and that the natural tear drops were opened and undated. 3. During an additional observation on 12/20/2023 at 9:55 AM of the medication cart on the Buttercup Unit, the following medications were observed to be expired: -1 bottle of Mucinex 400 mg expired 11/2023 -1 bottle of Aspirin 81 mg without a visible expiration date During a surveyor interview on 12/20/2023 following the above observation with Licensed Practical Nurse (LPN), Staff E, she acknowledged that the above-mentioned medications were expired and should have been discarded. 4. During a further observation on 12/20/2023 at approximately 10:00 AM of Lily Unit medication room, the inside of the refrigerator was observed to have water dripping down from the freezer. The packages of suppositories and Tuberculin that were not bagged were observed to be wet from the dripping water. During a surveyor interview following the observation with LPN, Staff F, she acknowledged that there was water in the medication refrigerator and the above-mentioned medications were wet from the dripping water. During an interview with the Director of Nursing Services on 12/20/2023 at 2:00 PM, she indicated that she would expect the staff to remove the expired medications from the medication carts as well as the medication storage rooms. Additionally, she indicated that the above-mentioned medications should have been discarded.

CONCERN (E)

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

Food Safety (Tag F0812)

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 ensure that the facility stores, distributes, and serves food in accordance with p...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that the facility stores, distributes, and serves food in accordance with professional standards for food safety relative to the main kitchen and 2 of 3 dining areas. Findings are as follows: 1. Record review of the Rhode Island Food Code 2018 edition, section 4-602.11 states in part, .(C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris . During the initial tour of the main kitchen on 12/18/2023 at 8:10 AM revealed the following observations: a. In the dishroom, a wall fan with a heavy accumulation of dust, currently in use, facing the dish machine in the direction of the clean pans b. In the walk-in refrigerator, there was built up debris on the condenser fan c. The hood slats above the stove had an accumulation of brown debris and grease During a follow up visit to the main kitchen on 12/19/2023 at 8:19 AM revealed the same wall fan with a heavy accumulation of dust, currently in use, facing the dish machine in the direction of the clean pans. During a surveyor interview following the above observation with Dietary Aide, Staff G, he acknowledged the fan had a high dust accumulation and was blowing in the direction of the clean pans. Additionally, he revealed the maintenance department takes care of cleaning it. During a surveyor interview on 12/20/2023 at 8:12 AM with the Maintenance Supervisor, he revealed that he does not have a cleaning schedule for the kitchen. He further revealed that if the fans or hood slats needed to be cleaned, he would expect to be notified. 2. Record review of the Rhode Island Food Code 2018 edition, section 3-202.15 Package Integrity states in part, Food Packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants . During the initial tour of the main kitchen on 12/18/2023 at 8:10 AM revealed the following in the dry storage area: -(1) 10 pound opened bag of macaroni half wrapped in plastic wrap -(2) 10 pound opened bags of penne pasta half wrapped in plastic wrap -(1) 10 pound opened bag of spaghetti covered loosely in plastic wrap During a surveyor interview on 12/18/2023 at 11:23 AM with the Director of Dining Services, she acknowledged the metal slats and the condenser fan needed to be cleaned. Additionally, she acknowledged that the opened bags of pasta should have been placed in a closed container to prevent contamination. 3. Record review of the Rhode Island Food Code 2018 edition, Section 5-202.13 Backflow Prevention, Air Gap, states, An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or nonFOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). During a follow up visit to the main kitchen, on 12/20/2023 at 11:46 AM, in the presence of the Director of Dining Services, revealed the ice machine's air gap was less than 1 inch. During a surveyor interview on 12/20/2023 immediately following the above observation, the Director of Dining Services acknowledged that the air gap needed to be longer to prevent contamination.

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

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Based on record review, surveyor observation, staff and resident 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 an unidentified respiratory illness for 2 of 3 nursing units and affecting Resident ID #s 5, 7, 8, 16, 34, 46, 54, 63, 68, 72, 77, and 285. Findings are as follows: 1. Review of a facility policy titled Infection Control Outcome and Process Surveillance and Reporting reviewed on 2/1/2023 states in part, .to detect possible communicable diseases or infections, plan control activities before communicable disease or infections can spread to others, and identify and manage potential outbreaks of disease . Review of a facility policy titled Patient Placement in Transmission Based Precautions revised on 5/1/2023 revealed in part, Purpose to prevent the transmission of infectious disease .Empirically initiate Transmission Based Precautions based on signs and symptoms that are consistent with a communicable disease .If laboratory test confirm diagnosis, continue with precautions indicated .if test(s) results are negative, adjust or discontinue precautions as indicated . According to the Viral Respiratory Pathogens Toolkit for Nursing Homes dated 12/5/2023 from the Centers of Disease Control and Prevention state in part, .When an acute respiratory infection is identified in a resident or [healthcare personnel], it is important to take rapid action to prevent the spread to others in the facility. While decisions about treatment, prophylaxis, and the recommended duration of isolation vary depending on the pathogen, [infection prevention control] strategies, such as placement of the resident in a single-person room, use of a facemask for source control, and physical distancing, are the same regardless of the pathogen .[Healthcare personnel] who enter the room of a resident with signs or symptoms of an unknown respiratory viral infection that is consistent with SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). This PPE [personal protective equipment] can be adjusted once the cause of the infection is identified .Test anyone with respiratory illness signs or symptoms. Selection of diagnostic tests will depend on the suspected cause of the infection (e.g., which respiratory viruses are circulating in the community or the facility, recent contact with someone confirmed to have a specific respiratory infection) and if the results will inform clinical management (e.g., treatment, duration of isolation). At a minimum, testing should include SARSCoV-2 [COVID-19] and influenza viruses with consideration for other causes (e.g., RSV) . a. Record review revealed Resident ID #285 was admitted to the facility in December of 2023 with diagnoses including, but not limited to, Respiratory Syncytial Virus (RSV) pneumonia and chronic congestive heart failure. Record review revealed the resident was on transmission-based precautions due to the diagnosis of RSV. b. Record review revealed Resident ID #5 was admitted to the facility in May of 2020 with diagnosis including, but not limited to, Alzheimer's disease and hydrocephalus (excess fluid build-up in fluid-containing cavities of the brain). Record review revealed a physician's order with a start date of 12/4/2023 for Geri-Tussin Oral Syrup every 6 hours as needed for cough. Review of the December 2023 Medication Administration Record (MAR) revealed the resident was receiving Geri-tussin on the following dates: 12/4/2023 12/5/2023 12/6/2023 12/7/2023 12/9/2023 12/10/2023 twice 12/16/2023 12/18/2023 Record review failed to reveal evidence that an RSV swab was obtained related to a recent RSV positive resident in the building. During surveyor observations on 12/18/2023, 12/19/2023, and 12/20/2023 failed to reveal evidence that the resident was on precautions related to signs and symptoms that are consistent with a communicable disease or infection while waiting on diagnostic testing. c. Record review revealed that Resident ID #7 was admitted to the facility in February of 2023 with diagnosis including, but not limited to, encounter for surgical aftercare following surgery on the digestive tract and diverticulitis (inflammation or infection of the pouches formed in the colon) of intestine without perforation or abscess without bleeding. Record review revealed the resident complained of a cough and sore throat on 12/15/2023. Record review revealed a physician order with a start date of 2/23/2023 for Geri-Tussin Oral Syrup every 6 hours as needed for cough. Review of the December 2023 MAR revealed the resident was receiving Geri-tussin on the following dates: 12/1/2023 12/2/2023 12/3/2023 12/4/2023 12/6/2023 12/7/2023 12/8/2023 12/9/2023 12/10/2023 12/12/2023 12/13/2023 12/14/2023 12/15/2023 12/16/2023 Further review of the December 2023 MAR revealed the above order was held from 12/17/2023 through 12/20/2023. Additional record review revealed a physician's order with a start date of 2/23/2023 for cepacol sore throat mouth/throat lozenge every 4 hours as needed for cough. Record review revealed the resident received cepacol sore throat mouth/throat lozenge on the following dates: 12/15/2023 twice 12/16/2023 twice 12/17/2023 12/18/2023 12/19/2023 three times During a surveyor observation on 12/18/2023 at 10:22 AM with the resident s/he was observed with nasal congestion and coughing. During a surveyor interview immediately following the above-mentioned observation with the resident, s/he revealed that s/he has a cold and was tested for COVID-19 but was not tested for the flu or RSV. Record review failed to reveal evidence that an RSV swab was obtained related to a recent RSV positive resident in the building. During surveyor observations on 12/18/2023, 12/19/2023, 12/20/2023, and 12/21/2023 failed to reveal evidence that the resident was on precautions related to signs and symptoms that are consistent with a communicable disease or infection while waiting on diagnostic testing. d. Record review revealed Resident ID #8 was admitted to the facility in December of 2022 with diagnosis including but not limited to, vascular dementia and bipolar disorder. During a surveyor observation on 12/18/2023 at 10:43 AM of the resident in the common area revealed the resident was congested and coughing. Record review failed to reveal evidence that an RSV swab was obtained related to a recent RSV positive resident in the building. During surveyor observations on 12/18/2023, 12/19/2023, 12/20/2023, and 12/21/2023 failed to reveal evidence that the resident was on precautions related to signs and symptoms that are consistent with a communicable disease or infection while waiting on diagnostic testing. e. Record review revealed Resident ID #16 was admitted to the facility in August of 2023 with diagnoses including, but not limited to, demyelination disease of central nervous system (condition that results in damage to the protective covering that surrounds nerve fibers in your brain, optic nerves and spinal cord) and vascular dementia. Record review revealed a physician's order with a start date of 12/17/2023 for guaifenesin liquid every 6 hours as needed for cough. During a surveyor observation on 12/18/2023 at 10:38 AM revealed the resident coughing with a runny nose. Record review revealed the resident received guaifenesin liquid on the following dates: 12/17/2023 12/18/2023 12/20/2023 Record review failed to reveal evidence that an RSV swab was obtained related to a recent RSV positive resident in the building. During surveyor observations on 12/18/2023, 12/19/2023, 12/20/2023, and 12/21/2023 failed to reveal evidence that the resident was on precautions related to signs and symptoms that are consistent with a communicable disease or infection while waiting on diagnostic testing. f. Record review revealed Resident ID #34 was admitted to the facility in November of 2023 with diagnoses including, but not limited to, dementia and hypertensive urgency (severe elevation in blood pressure without signs or symptoms of organ damage). Record review revealed a physician's order with a start date of 12/15/2023 for guaifenesin liquid every 6 hours as needed for cough. Record review of the December 2023 MAR revealed the resident received the above mentioned medication on the following dates for cough: 12/17/2023 12/18/2023 12/19/2023 Further review revealed a physician's order with a start date of 12/19/2023 to obtain a flu swab. During a surveyor observation on 12/18/2023 at 10:02 AM revealed the resident in his/her bed coughing. During a subsequent surveyor observation on 12/18/2023 at 12:19 PM revealed the resident in the dining room coughing. Record review failed to reveal evidence that an RSV swab was obtained related to a recent RSV positive resident in the building. During surveyor observations on 12/18/2023, 12/19/2023, 12/20/2023, and 12/21/2023 failed to reveal evidence that the resident was on precautions related to signs and symptoms that are consistent with a communicable disease or infection while waiting on diagnostic testing. g. Record review revealed Resident ID #46 was admitted to the facility in April of 2022 with diagnoses including, but not limited to, chronic obstructive pulmonary disease and dementia. Record review revealed a physician's order with a start date of 12/15/2023 for Claritin 10 milligrams (mg) every morning for cold symptoms for 10 days. Record review of a progress note authored by the Nurse Practitioner (NP) dated 12/14/2023 states in part, .I find pt [patient] in [his/her] room and [s/he] has complaints of allergy symptoms of a runny nose and congestion .[patient] to use .claritin as directed . During a surveyor observation during the resident council task on 12/19/2023 at 2:00 PM revealed the resident coughing. Record review failed to reveal evidence that an RSV swab was obtained related to a recent RSV positive resident in the building. During surveyor observations on 12/18/2023, 12/19/2023, 12/20/2023, and 12/21/2023 failed to reveal evidence that the resident was on precautions related to signs and symptoms that are consistent with a communicable disease or infection while waiting on diagnostic testing. h. Record review revealed Resident ID #54 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, chronic obstructive disorder and acute respiratory failure with hypoxia [below-normal level of oxygen in your blood]. Record review revealed the resident had an elevated temperature of 100.1 on 12/16/2023. Record review revealed a progress note dated 12/17/2023 which states in part, .resident lethargic most of shift. arousable for brief periods of time. unable to stay awake long enough to take food or fluid. labs ordered for am, [chest x-ray] due to intermittent cough and recent fever . Record review revealed the resident was seen by the NP on 12/18/2023 and a flu test was ordered. During a surveyor interview on 12/20/2023 at 8:43 AM with Registered Nurse, Staff A, she reviewed the resident's record and revealed that she was unable to find that a flu swab was obtained as ordered. During a surveyor interview on 12/20/2023 at 12:50 PM with the NP she revealed that she was unaware that the facility did not obtain a flu swab. Further record review failed to reveal a flu swab was obtained until 12/20/2023 after it was brought to the facility's attention by the surveyor. Additional record review failed to reveal evidence that an RSV swab was obtained related to a recent RSV positive resident in the building. During surveyor observations on 12/18/2023, 12/19/2023, 12/20/2023, and 12/21/2023 failed to reveal evidence that the resident was on precautions related to signs and symptoms that are consistent with a communicable disease or infection while waiting on diagnostic testing. i. Record review revealed that Resident ID #63 was admitted to the facility in December of 2022 with diagnosis including, but not limited to, asthma and type 2 diabetes mellitus. Record review revealed a progress noted dated 12/18/2023 which states in part, .GuaiFENesin .Tablet Extended Release 12 Hour 600 MG [milligrams] Give 1 tablet by mouth every 12 hours as needed for cough . Record review of a progress note dated 12/19/2023 authored by the NP states in part, .I find pt [patient] in [his/her] room and [s/he] has complaints of a cough today .Pt to take mucinex 600 mg [by mouth twice a day] for 7 days. Pt to increase PO [by mouth] fluids. I have ordered a stat chest xray on pt. I have also ordered stat flu and covid tests on pt . Additional record review failed to reveal evidence that an RSV swab was obtained related to a recent RSV positive resident in the building. During surveyor observations on 12/18/2023, 12/19/2023, 12/20/2023, and 12/21/2023 failed to reveal evidence that the resident was on precautions related to signs and symptoms that are consistent with a communicable disease or infection while waiting on diagnostic testing. j. Record review revealed that Resident ID #68 was admitted to the facility in August of 2023 with diagnoses including, but not limited to, chronic obstructive pulmonary disease and dementia. Record review revealed a physician's order with a start date of 8/27/2023 for Geri-Tussin Oral Liquid Give 10 milliliters (ml) by mouth every 4 hours as needed for cough. Record review of the December 2023 MAR revealed that the resident received an as needed dose of the above-mentioned medication on 12/20/2023. Record review revealed a physician's order with a start date of 10/9/2023 for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3 ML 3 ml, inhale orally every 6 hours as needed for shortness of breath or wheezing. Record review of the December 2023 MAR revealed that the resident received an as needed dose of the above-mentioned medication on 12/20/2023. During a surveyor observation on 12/21/2023 failed to reveal evidence that the resident was on precautions related to signs and symptoms that are consistence with a communicable disease or infection while waiting on diagnostic testing. k. Record review revealed that Resident ID #72 was admitted to the facility in September of 2023 with diagnosis including, but not limited to, pneumonia and bipolar disorder. Record review revealed a physician's order with a start date of 12/15/2023 for Geri-Tussin Oral Liquid Give 10 ml by mouth every 4 hours as needed for cough. Review of the December MAR revealed the resident received the above medication on 12/15/2023. Record review revealed the following progress notes: 12/15/2023 at 3:35 PM Resident is alert and able to make needs known, [complaint of] cough and sore throat, lung sounds diminished, temp 97.1, covid test negative, reported to [doctor] received new order for Guaifenesin-DM 100-10 mg/5 ml and to obtain a chest xray. cough medication administered with good effect. chest xray ordered. 12/15/2023 at 6:44 PM Guaifenesin-DM Liquid .Give 10 ml by mouth every 6 hours as needed for Cough .Administration was: Ineffective. Additional record review failed to reveal evidence that an RSV swab was obtained related to a recent RSV positive resident in the building. During surveyor observations on 12/18/2023 and 12/19/2023 failed to reveal evidence that the resident was on precautions related to signs and symptoms that are consistent with a communicable disease or infection while waiting on diagnostic testing. l. Record review revealed that Resident ID #77 was admitted to the facility in October of 2023 with diagnoses including, but not limited to, dementia and adjustment disorder. Review of the resident progress notes revealed the following entries: 12/19/2023 authored by the NP states in part, .find pt sitting in [his/her] chair today and [s/he] is noted to have a cough on exam today with some fine rales [abnormal lung sounds]. I have ordered chest xray, flu, covid. Pt to remain on cough syrup as directed .Respiratory [positive] cough with diffuse coarse breath sounds. NO wheezing, fine rales noted . 12/19/2023 1:44 PM Resident continues with cough and congestion, seen by NP received new order to obtain chest ray and to test for covid 19 and flu. Record review revealed a physician's order with a start date of 12/16/2023 for Geri-Tussin Oral Liquid Give 10 ml by mouth every 4 hours as needed for cough. Review of the December MAR revealed the resident received the above mentioned medication on 12/16/2023. Additional record review failed to reveal evidence that an RSV swab was obtained related to a recent RSV positive resident in the building. During surveyor observations on 12/18/2023, 12/19/2023, 12/20/2023, and 12/21/2023 failed to reveal evidence that the resident was on precautions related to signs and symptoms that are consistent with a communicable disease or infection while waiting on diagnostic testing. During a surveyor interview with the Infection Preventionist (IP) on 12/20/2023 at 9:05 AM during the infection control task, she revealed that she was unaware of more than 2 residents having a respiratory illness but, that they had a resident recently that was admitted with RSV. When presented with the list of residents who were symptomatic with a respiratory illness, she was unable to provide evidence of a tracking mechanism used to detect possible communicable diseases or infections and that the respiratory illness was identified and managed to prevent a potential outbreak of disease. Additionally, she revealed that she had not reported a possible outbreak to the state agency or tested any of the identified residents for RSV. During a surveyor interview with the NP on 12/20/2023 at 12:45 PM, she acknowledged that there was a positive resident for RSV recently and revealed that she will now review the symptomatic residents and test them as needed for RSV. During a surveyor interview on 12/21/2023 at 8:08 AM with RN, Staff A, she revealed that no residents were on precautions related to a respiratory illness but that a lot of residents were coughing. During a surveyor interview on 12/21/2023 at 8:16 AM with the IP she revealed that she still had not notified the state agency of a possible respiratory illness outbreak but did obtain swabs to test residents for RSV. Additionally, she was unable to provide evidence of an effective infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to an identified respiratory illness for 2 of 3 nursing units. During a surveyor interview with the Center for Acute Infectious Disease Epidemiology at the Rhode Island Department of Health on 12/21/2023 at 10:42 AM, she revealed that the facility did not notify them of a potential respiratory outbreak. She further revealed that the directive at the time would have been to utilize standard and droplet precautions which consists of gown, gloves, and mask for symptomatic residents. She further revealed there is an increase in RSV cases in the community.

CONCERN (F)

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

Deficiency F0838 (Tag F0838)

Could have caused harm · This affected most or all residents

Based on record review and staff interview, it has been determined that the facility failed to document a facility-wide assessment to determine what resources are necessary to care for its residents c...

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Based on record review and staff interview, it has been determined that the facility failed to document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies which must be reviewed and updated as necessary, and at least annually. Additionally, the facility failed to review and update the assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. Findings are as follows: Review of a facility provided document titled, Facility Assessment dated 10/17/2023 through 12/30/2023 failed to reveal the following components required according to Appendix PP: - The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population - The staff competencies that are necessary to provide the level and types of care needed for the resident population - The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population - Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services Further review of the document titled Facility Assessment, failed to reveal evidence of the facility's resources, which include but are not limited to: - All buildings and/or other physical structures and vehicles - Equipment (medical and non- medical) - Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies - All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care - Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and - Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations. During a surveyor interview on 12/20/2023 at 2:45 PM with the Interim Administrator he acknowledged that the facility assessment was incomplete and failed to provide evidence of the required information.

Aug 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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

Based on record revie, 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 3 residents reviewed for b...

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Based on record revie, 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 3 residents reviewed for behaviors, Resident ID #2. Findings are as follows: Review of the CMS [Centers for Medicare and Medicaid Services] RAI [Resident Assessment Instrument] 3.0 Manual, states in part, .The items in this section identify behavioral symptoms in the last seven days that may cause distress to the resident, or may be distressing or disruptive to facility residents, staff members or the care environment .behaviors include those that are potentially harmful to the resident himself or herself .identification of the frequency and the impact of behavioral symptoms on the resident and on others is critical to distinguish behaviors that constitute problems .once the frequency and impact of behavioral symptoms are accurately determined, follow-up evaluation and care plan interventions can be developed to improve the symptoms or reduce their impact .Frequency .Steps for Assessment 1. Review the medical record for the 7-day look-back period .2. Interview staff, across all shifts and disciplines, as well as others who had close interactions with the resident during the 7-day look-back period, including family or friends who visit frequently or have had contact with the resident .3. Observe the resident in a variety of situations during the 7-day look-back period .code based on whether the symptoms occurred and not based on an interpretation of the behavior's meaning .code 0 if behavioral symptoms were not present in the last 7 days .use this code if the symptom has never been exhibited or if it previously has been exhibited but has been absent in the last 7 days . Record review revealed Resident ID #2 was readmitted to the facility in June of 2023, with diagnoses including, but not limited to, dementia, major depressive disorder and anxiety. Review of a Minimum Data Set (MDS) Assessment, dated 8/23/2023, revealed that the resident was coded 0 for behaviors, indicating that s/he did not exhibit any behaviors during the 7-day look back period. Review of the resident's progress notes, during the 7-day look back period, revealed the following notes: - 8/20/2023 at 3:04 PM, states in part, .another .resident was pacing around unit and accidentally bumped into [resident's name redacted] walker, CMT (certified medication technician) witnessed the resident forcefully grab other resident by the hair . - 8/20/2023 at 8:27 PM, states in part, .very argumentative with staff and other residents in dining room several times during shift . -8/21/2023 at 10:03 PM, states in part, .too numerous to count redirects, pacing constantly .trying to enter shower while CNA giving other resident a shower .during redirect grabbed door and banged on it, swore . -8/23/2023 at 11:02 PM, states in part, .arguing, swearing at female resident to go to a different table . During a surveyor interview on 8/31/2023 at 12:15 PM, with the Social Service Director (SSD), Staff A, she acknowledged that the resident has a long-standing history of exhibiting behaviors which include, but are not limited to, resident-to-resident abuse, wandering, verbal outbursts, physical aggression including combativeness, and resistiveness/refusals of care. In addition, the SSD acknowledged completing the 8/23/2023 MDS Assessment, and acknowledged that it was not coded correctly and did not accurately reflect the resident's behavioral status, per the 7-day look back period of the resident's medical record. During a surveyor interview on 8/31/2023 at 12:50 PM, with the Director of Nursing Services, and Administrator, they indicated that they would have expected the resident's 8/23/2023 MDS Assessment to accurately reflect the resident's behaviors.

Aug 2023 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

Safe Environment (Tag F0584)

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 maintain a safe, clean, sanitary, homelike environment relative to bed sheets and ...

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Based on record review, surveyor observation, and staff interview, it has been determined that the facility failed to maintain a safe, clean, sanitary, homelike environment relative to bed sheets and privacy curtains for 2 of 3 resident rooms observed, Resident ID #s 2 and 3. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 8/7/2023, alleges that the facility .has blood on the floors and privacy curtains on the [D] unit and is filthy with fruit flies everywhere . 1. Record review revealed Resident ID #2 was readmitted to the facility in July of 2023, with diagnoses to include, but not limited to, vascular dementia and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). Multiple surveyor observations on 8/9/2023 between the hours of 1:30 PM through 4:15 PM, revealed the resident's bed sheets were stained with brown colored matter on the bottom fitted sheet, as well as on the top flat sheet. During a surveyor interview on 8/9/2023 at 2:30 PM with Licensed Practical Nurse, Staff A, she acknowledged that there was brown colored matter on Resident ID #2's bed sheets. Additionally, she acknowledged that the bed sheets should be changed. 2. Record review revealed Resident ID #3 was readmitted to the facility in February of 2022, with diagnoses to include, but not limited to, dementia and depression. Multiple surveyor observations on 8/9/2023 between the hours of 1:30 PM through 4:45 PM, revealed the resident's privacy curtain had brown and red colored matter on it. During a surveyor interview on 8/9/2023 at 2:35 PM with Staff A, she acknowledged that there was brown and red colored matter on Resident ID #3's privacy curtain. Additionally, she acknowledged that the privacy curtain should be changed. During a surveyor interview on 8/9/2023 at approximately 4:15 PM with the Administrator and Director of Nursing Services, they were unable to provide a reason as to why the above-mentioned areas had not been cleaned. Additionally, they revealed that they would expect the bed sheets and privacy curtains to be clean.

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 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 f...

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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 following a physician's order for 1 of 1 resident reviewed, Resident ID #2. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 states: The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review revealed Resident ID #2 was readmitted to the facility in July of 2023, with diagnoses to include, but not limited to, vascular dementia and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). Review of a physician order dated 5/10/2022, revealed the resident is to have Prevalon booties (a boot with a cushioned bottom that floats the heel off the surface of the mattress, helping to reduce pressure) to bilateral feet when lying in bed. Upon further review a physician's order dated 7/21/2022 revealed a left hand-palm guard (a hand brace that is used to prevent fingers from digging into the palm of your hand to prevent further skin damage) should be worn continuously with an exception to remove it for one hour, to clean and dry the hand. Multiple surveyor observations on 8/9//2023, between the hours of 1:30 PM through 4:15 PM, revealed Resident ID #2 was lying in bed and did not have Prevalon booties to bilateral feet, or a palm guard to his/her left hand. During a surveyor interview on 8/9/2023 at approximately 3:50 PM with Licensed Practical Nurse, Staff B, she acknowledged that the resident did not have the Prevalon booties or palm guard in place as ordered. During a surveyor interview on 8/9/2023 at approximately 4:15 PM, with the Administrator and Director of Nursing Services, they were unable to provide evidence or an explanation why the physician's orders were not followed.

Jan 2023 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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected multiple residents

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interviews, it has been determined that the facility failed to protect the resident's right to be free from neglect for 3 of 5 residents reviewed, Resident ID #s 4, 5, and 6 . Review of a facility reported incident submitted to the Rhode Island Department of Health on 1/8/2023 states in part, Upon change of shift it was brought to the nurses attention that multiple residents on abuser's assignment were not provided care on 7-3 shift [Resident ID #s 4, 5 and 6]. Two residents stated that they had not been washed or changed all day .One was found to be covered in urine and feces. Findings are as follows: Review of a facility policy titled, NSG200 [Nursing] Activities of Daily Living (ADLs) revised 6/1/2021, states in part, .must provide the necessary care and services to ensure that a patient's activities of daily living (ADL) activities are maintained .(ADLs) include: Hygiene - bathing, dressing, grooming, [and] oral care .Elimination - toileting .ensure ADLs are provided in accordance with accepted standards of practice, the care plan . 1. Record review revealed Resident ID #5 was admitted to the facility in March of 2022 with diagnoses including, but not limited to, muscle weakness and morbid obesity. Review of an MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating intact cognition. Further review of the assessment revealed Resident ID #5 is frequently incontinent of urine and always incontinent of bowel. Additionally, s/he requires extensive assistance of two or more people for toileting and personal hygiene, and one person assistance for dressing. Review of a care plan focus area revised on 6/20/2022 states in part, .requires assistance/is dependent for ADL care in .grooming, personal hygiene, dressing .toileting . with an intervention revised on 11/29/2022 for Provide resident/patient with total assist .bathing, dressing, grooming. Review of a written statement dated 1/9/2023 authored by Staff A, stated in part, .I had [Resident ID #5] on my assignment, I went in a few times when [s/he] rang and continued on my way. I assumed at the end of the day I was done w/[with] my assignment, not realizing that I had not completing [SIC] my assignment . During a surveyor interview on 1/9/2023 at approximately 1:00 PM with Staff A, she revealed rounds are typically conducted twice a shift for incontinent residents. She acknowledged assistance with ADLs and incontinence care was not provided for Resident ID #5. Additionally, she recalled only entering his/her room twice responding to the call system to assist with bed controls and to fix his/her oxygen tubing. During a surveyor interview on 1/9/2023 at 2:30 PM with Resident ID #5, s/he revealed that s/he used the call system on 1/8/2023 before lunch and spoke with a staff member via intercom informing the staff member s/he needed incontinence care as s/he had a bowel movement. Resident ID #5 was told to wait as lunch trays were being distributed. S/he revealed it was not until the next shift, sometime after 3:00 PM, that incontinence care was provided to him/her. S/he indicated that s/he remained soiled of urine and feces for approximately 3-4 hours from before lunch time until after 3:00 PM. During a surveyor interview on 1/10/2023 at 8:15 AM with Registered Nurse (RN), Staff B, she revealed she entered Resident ID #5's room at approximately 1:00 PM, and the resident had asked her to be washed up and have care done. She further revealed that she informed Staff A, that Resident ID #5 was requesting to have his/her care completed. Staff B followed up approximately 30 minutes later with Staff A to ensure care was completed. Staff A indicated to Staff B that the resident received care. At shift change, Staff B was informed by an oncoming second shift NA, Staff C, that the resident had used the call system and indicated s/he was still soiled and was never provided with incontinence care during the 7 AM to 3 PM shift on 1/8/2023. Staff B than entered with another 2nd shift NA, Staff D, to provide the resident incontinence care at approximately 3:15 PM. Record review of a written statement dated 1/8/2023 authored by Licensed Practical Nurse, Staff G, indicates that she was informed by Staff B that Resident ID #5 was found completely soiled and Staff A did not wash or change him/her on 1/8/2023. 2. Record review revealed Resident ID #6 was admitted to the facility in April of 2017 with diagnoses including, but not limited to, dementia and contracture of muscle(s). Review of an MDS assessment dated [DATE] revealed the resident is rarely/never understood indicating his/her mental status and cognition could not be assessed. Further review of the assessment revealed Resident ID #6 is always incontinent of urine and bowel. Additionally, s/he requires extensive assistance of one person for dressing, toileting, and personal hygiene. Review of a care plan focus area revised on 5/3/2021 states in part, .dependent for ADL care related to cognitive loss . with an intervention initiated 11/29/2022 for Provide resident/patient with total assist of 1 for bathing, dressing, grooming. During a surveyor telephone interview on 1/10/2023 at approximately 9:30 AM with Staff A, she revealed she was assigned care for Resident ID #6 on 1/8/2023 from 7:00 AM to 3:00 PM. She acknowledged the resident is incontinent of urine and bowel. Additionally, she revealed the resident was not provided incontinence care for the entire shift, approximately 8 hours. During a surveyor telephone interview on 1/10/2023 at 10:59 AM with RN, Staff E, the 2nd shift unit nurse, she revealed she was informed by Staff C, at approximately change of shift, the resident was soaked, indicating s/he was heavily incontinent of urine. During a surveyor telephone interview on 1/10/2023 at 11:11 AM with Staff D, she revealed the resident looked uncomfortable in his/her recliner, moving around, which is typical behavior when s/he is incontinent. Additionally, she revealed at that time, the resident was returned to his/her room and provided incontinence care at approximately 4:00 PM, indicating the resident had not received incontinence care for at least 9 hours. 3. Record review revealed Resident ID #4 was admitted to the facility in August of 2022 with diagnoses including, but not limited to, muscle weakness and morbid obesity. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. Further review of the assessment revealed Resident ID #4 is occasionally incontinent of urine and frequently incontinent of bowel. Additionally, s/he requires extensive assistance of two or more people for dressing, toileting, and personal hygiene. Review of a care plan focus area revised on 11/29/2022 states in part, .extensive to dependent for .grooming, personal hygiene, dressing . with an intervention initiated 12/5/2022 for Provide resident/patient with adl care, extensive care . Record review of the assignment sheet for 1/8/2023 revealed that the perpetrator, Nursing Assistant (NA), Staff A was assigned to care for Resident ID #4 on 1/8/2023 from 7 AM to 3 PM. During a surveyor interview with the resident on 1/10/2023 at 8:52 AM, s/he indicated that nobody washed or dressed him/her on 1/8/2023 during the 7 AM to 3 PM shift. During a surveyor telephone interview on 1/10/2023 at approximately 9:30 AM with Staff A, she acknowledged she was responsible to care for Resident ID #4. Additionally, she revealed she did not provide routine personal care or provide assistance with his/her ADLs on 1/8/2023 between 7:00 AM - 3:00 PM. During a surveyor interview on 1/10/2023 at 8:43 AM with Nursing Assistant (NA), Staff J, she revealed she was one of three NA's assigned to the unit on first shift on 1/8/2023, working alongside another NA, Staff H, Staff A, Staff B, and Certified Medical Technician, Staff I. She further revealed that Resident ID #s 4, 5, and 6 were not on her assignment, nor did she assist in, or witness, other staff members providing routine ADL care for these residents on 1/8/2023. Additionally, two unsuccessful telephone interviews were attempted on 1/10/2023 in efforts to speak with Staff I and Staff H, at 9:30 AM and 9:35 AM, respectively. During a surveyor interview on 1/10/2023 at approximately 2:30 PM with the Regional Clinical Director in the presence of the Administrator and interim Director of Nursing Services, they revealed routine incontinence care should be provided at a minimum of every 2 hours. They were unable to provide evidence that the above mentioned residents received the necessary assistance with ADLs in accordance with accepted standards of practice and per the plan of care.

Dec 2022 2 deficiencies 2 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

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

Based on record review and staff and resident interview, it has been determined that the facility failed to use a two-person transfer, as determined by the plan of care, during a transfer from the res...

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Based on record review and staff and resident interview, it has been determined that the facility failed to use a two-person transfer, as determined by the plan of care, during a transfer from the resident's bed to a commode, resulting in the resident sustaining fractures, for 1 of 3 residents reviewed for falls, Resident ID #1. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 12/20/2022 states in part, .resident had fall transferring to commode on 12/16/2022 with CNA [Certified Nursing Assistant] Xrays ordered, completed and received on 12/17/22 [negative] for FX [fracture]. Resident with lower Rt [right] leg pain. Additional xrays of knee, Tib/ Fib [tibia/fibula] and ankle done on 12/18/22 neg [negative] for FX. Seen 12/19/2022 by NP [Nurse practitioner], on physical exam felt should be evaluated in hospital setting . CT [CT scan- Uses several X-ray images and computer processing to create cross sectional images] and xrays repeated. Impression: 1: Impacted lateral femoral condyle fx and possible nondisplaced fx of medial condyle [ A femoral condyle is the ball-shape located at the end of the femur (thigh bone). There are two condyles on each leg known as the medial and lateral femoral condyles]. 2: Nondisplaced fx of the proximal medial tibial metaphysis [when the tibia, the long bone of the lower leg sustains a break or crack without a fragment of the bone becoming separated]. Record review revealed the resident was admitted to the facility in February of 2021 and has diagnoses including, but not limited to, difficulty in walking, osteoarthritis, presence of unspecified artificial hip joint, unsteadiness on feet and arthritis due to other bacteria of the right hip. Review of the quarterly Minimum Data Set (MDS) Assessment (entails a comprehensive, standardized assessment of each resident's functional capabilities and health needs) dated 9/16/2022 revealed a Brief Interview for Mental Status score of 14 out of 15, indicating the resident is cognitively intact. Record review of the resident's care plan revealed the focus area initiated on 2/15/2021, .requires assistance/is dependent for ADL [activities of daily living] care in bathing, grooming, personal hygiene, dressing, bed mobility, transfer, locomotion, toileting related to .weakness, arthritis, presence of vascular implants [long -term implantation of a patented medical device used in the treatment of an abnormality in the vein or an artery] . Interventions on the care plan at the time of the fall were as follows: Provide resident /patient with extensive assist of 2 or if able limited with slide board [equipment that is used to bridge the gap between two surfaces allowing for assistance with transfers] if resident wants to use date initiated 11/28/2022. Provide resident /patient with total assist of 2 for transfers using a mechanical lift full body sling, large date initiated 11/28/2022. Record review of nursing progress notes revealed the following: -12/16/2022 at 8:50 PM revealed Resident was transferring from bed to commode with staff then fell and is complaining of upper right leg pain. Pt does have hx [history] arthritis of [his/her] right hip .Patient is at risk for falls due to the following Recent Generalized weakness .Orders: Stat right femur and right hip xrays . - 12/17/2022 at 1:28 PM revealed .Radiology in and did xrays of right upper leg. At time of exam resident reported [his/her] pain being in the lower leg; anterior aspect of leg tender to palpation. Some swelling present in upper leg and lower leg .STAT xray (2 views) of Knee, Tib/Fib, and ankle ordered . Review of an encounter note dated 12/19/2022 by the Nurse Practitioner revealed in part, .Per review of right leg xray pt is noted to have old fracture involving right interochanteric femur [between the points where the muscles of the thigh and hip attach] with complete absence of right femoral head and neck, with moderate displacement of femoral shaft. Pt [patient] will be sent to .ER for further evaluation . Review of an encounter note dated 12/20/2022 by the Nurse Practitioner revealed in part, .Pt was sent to the hospital for further evaluation. While at the hospital pt was noted on xray of the right tibia fibula right knee and right femur noted to have impacted lateral femoral condyle fracture and possible nondisplaced fracture of the medial condyle. Nondisplaced fracture of the proximal medial tibial metaphysis. CT [cat scan] of the right knee noted Fracture of the tibial tuberosity [is caused by injury from violent tension forces on the tibial tuberosity] with associated soft tissue swelling . During a surveyor interview on 12/21/2022 at approximately 3:30 PM with CNA, Staff A, she revealed that the resident called her in to the room to help [him/her] to the commode from the bed. She acknowledged that she transferred the resident independently without the use a mechanical lift or a slide board. She was unable to explaint to the surveyor where she could find information relative to a resident's transfer requirements. During a surveyor interview on 12/21/2022 at 2:21 PM with the resident, s/he revealed that s/he really had to go to the bathroom so s/he was calling for staff assistance. A CNA came into the room by herself and had me grab her arm to when I fell. I now have two fractures. During a surveyor interview on 12/21/2022 at approximately 4:00 PM with the Director of Nursing Services, she acknowledged that the resident required two staff for transfers. She further acknowledged that on 12/16/2022 the resident was transferred by one CNA, which lead to a fall resulting in fractures.

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 F0726 (Tag F0726)

A resident was harmed · This affected 1 resident

Based on record review, and staff interview, it has been determined that the facility failed to ensure nursing staff have the appropriate competencies and skill sets to provide nursing and related ser...

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Based on record review, and staff interview, it has been determined that the facility failed to ensure nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety as identified in the plan of care for 1 of 3 residents reviewed for falls, Resident ID #1. Findings are as follows: Record review revealed the resident was admitted to the facility in February of 2021 and has diagnoses including, but not limited to, difficulty in walking, osteoarthritis (inflammation of one or more joints), presence of unspecified artificial hip joint, unsteadiness on feet and arthritis due to other bacteria of the right hip. Review of the quarterly Minimum Data Set (MDS) Assessment (entails a comprehensive, standardized assessment of each resident's functional capabilities and health needs) dated 9/16/2022 revealed a Brief Interview for Mental Status score of 14 out of 15, indicating the resident is cognitively intact. Record review of a nursing note dated 12/16/2022 at 8:50 PM revealed Resident was transferring from bed to commode with staff then fell and is complaining of upper right leg pain . Record review of the resident's care plan revealed the focus area initiated on 2/15/2021, .requires assistance/is dependent for ADL [activities of daily living] care in bathing, grooming, personal hygiene, dressing, bed mobility, transfer, locomotion, toileting related to .weakness, arthritis, presence of vascular implants [long -term implantation of a patented medical device used in the treatment of an abnormality in the vein or an artery] . Interventions on the care plan at the time of the fall were as follows: Provide resident /patient [Pt] with extensive assist of 2 or if able limited with slide board [equipment that is used to bridge the gap between two surfaces allowing for assistance with transfers] if resident wants to use date initiated 11/28/2022. Provide resident /patient with total assist of 2 for transfers using a mechanical lift full body sling, large date initiated 11/28/2022. Review of an encounter note dated 12/19/2022 by the Nurse Practitioner revealed in part, Per nursing pt has fell over the weekend .Per review of right leg xray pt is noted to have old fracture involving right interochanteric femur [between the points where the muscles of the thigh and hip attach] with complete absence of right femoral head and neck, with moderate displacement of femoral shaft. Pt [patient] will be sent to .ER for further evaluation . Review of an encounter note dated 12/20/2022 by the Nurse Practitioner revealed in part, .Pt was sent to the hospital for further evaluation. While at the hospital pt was noted on xray of the right tibia fibula [bones in the lower legs] right knee and right femur noted to have impacted lateral femoral condyle fracture and possible nondisplaced fracture of the medial condyle. Nondisplaced fracture of the proximal medial tibial metaphysis [when the tibia, the long bone of the lower leg sustains a break or crack without a fragment of the bone becoming separated]. CT [cat scan] of the right knee noted Fracture of the tibial tuberosity [is caused by injury from violent tensile forces on the tibial tuberosity] with associated soft tissue swelling . During a surveyor interview on 12/21/2022 at approximately 3:30 PM with CNA, Staff A, she revealed that the resident called her in to the room to help [him/her] to the commode from the bed. She acknowledged that she transferred the resident independently without the use a mechanical lift or a slide board. She was unable to explain to the surveyor where she could find information relative to a resident's transfer requirements. Record review of a policy provided by the facility titled, .Performance Appraisal revealed in part, .Managers of [ company name redacted] .will meet with their regular full-time, regular part-time, and regular casual employees at least annually to conduct a performance appraisal or have a performance based conversation. In-service education will be provided based on the outcome of these reviews .PURPOSE To recognize performance, measure results, establish development opportunities, and set goals for the coming year .PROCESS 1. The performance review process is an opportunity for an employee and their supervisor to talk openly about how each other feels about how the employee is doing in their position and set performance and development goals for the upcoming year . Review of Staff A's personnel file revealed that her last documented performance appraisal was signed and dated on 1/16/2019. Further review failed to reveal evidence of any performance appraisals after 1/16/2019. Indicating the provided facility policy, .In-service education will be provided based on the outcomes of these reviews . was not followed. During a surveyor interview on 12/21/2022 at approximately 3:45 PM with the Human Resource Manager she was unable to provide evidence that yearly performance appraisals were completed for Staff A, since 1/16/2019. Record review of an individual performance improvement plan provided to this surveyor on 12/21/2022, which was to be initiated with CNA Staff A on 12/22/2022, revealed in part, Reason Description: Unsatisfactory job performance .Date of Event: 12/16/2022 .Description of Event: [Staff A] transferred resident without gait belt, not following plan of care (2 person transfer [with] gait belt) resulting in resident falling . During a surveyor interview on 12/21/2022 at approximately 4:00 PM with the Director of Nursing Services, she acknowledged that the resident requires two staff members for all transfers. She further acknowledged that on 12/16/2022 the resident was transferred by one CNA, which lead to a fall resulting in fractures. Additionally, she acknowledged that the facility failed to follow its policy or complete annual performance appraisals for Staff A, since 1/16/2019.

Dec 2022 3 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

Deficiency F0658 (Tag F0658)

Someone could have died · 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 not following physician's order for 1 of 7 residents r...

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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 not following physician's order for 1 of 7 residents 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 . Review of a facility reported incident submitted to the Rhode Island Department of Health on 11/16/2022 indicates that at approximately 7:30 PM on 11/15/2022, during the evening snack pass, the resident was given a tuna sandwich and a drink. At approximately 9:00 PM, the nurse went into room to administer medications to the roommate and noticed that the resident was not breathing. His/her upper dentures were found in his/her bed, his/her lower dentures were in his/her mouth with a bite of the sandwich. Record review revealed the resident was re-admitted to the facility in August of 2019 with a diagnosis which included, but is not limited to, dysphagia, oropharyngeal phase (difficulty swallowing) following a choking event in the facility. Record review revealed a progress note dated 11/15/2022 at 11:04 PM which states in part, at 9pm, resident found deceased . time of death 9:10pm. found with half eaten sandwich in mouth. upon cleaning mouth, dentures pulled out of back of mouth or throat by cna [certified nursing assistant] . Record review revealed a physician's order with a start date of 7/19/2022 which states, RESIDENT NEEDS TO BE OUT OF BED TO EAT FOOD DUE TO CHOKING RISK. Record review of the November 2022 Medication Administration Record revealed the above-mentioned order was documented as completed twice daily, including on 11/15/2022, the day the incident occurred. Record review of the facility provided staff statements, revealed that the resident was provided a sandwich while in bed around 7:30 PM on 11/15/2022. During a surveyor interview on 11/21/2022 at 12:17 PM with the Director of Nursing Services she was unable to provide evidence the physician's order for the resident to be out of bed to eat food due to the resident being a choking risk was followed. During a surveyor interview on 11/22/2022 at 9:07 AM with the Medical Director, she revealed that she was aware that the resident had a history of choking. Furthermore, she revealed she would have expected the staff to follow the physician's order.

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 that each resident receives...

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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 each resident receives adequate supervision to prevent accidents relative to eating for 1 of 7 residents reviewed, Resident ID #1. Findings are as follows: Review of a facility policy titled, Meal Service with a revision date of 6/1/2021 states in part, Policy: Person-centered meal service includes the delivery of a safe, sanitary, and comfortable environment for meals . Review of a facility reported incident received by the Rhode Island Department of Health on 11/16/2022 states in part, At approx. [approximately] 7:30 pm during evening snack pass resident was given a tuna sandwich and drink by request. Resident was sitting with bed elevated and call light with in reach. At approx. 9 pm nurse went into room to administer meds to roommate and noticed [resident] was not breathing. [His/her] dentures were found in bed, [his/her] lowers were in [his/her] mouth with a bite of sandwich . Record review revealed that the resident was re-admitted to the facility in August of 2019 with diagnoses including, but not limited to, dysphagia, oropharyngeal phase (difficulty swallowing) and schizophrenia. Review of a Minimum Data Set assessment dated [DATE], revealed the resident required supervision of one staff member to eat. Review of the November Medication Administration Record revealed an order with a start date of 7/19/2022 that stated, RESIDENT NEEDS TO BE OUT OF BED TO EAT FOOD DUE TO CHOKING RISK. Every day and evening shift for protection. The above order was signed as completed on 11/15/2022. Review of a Speech Therapy SLP [Speech Language Pathology] Discharge Summary signed 11/16/2022 stated in part, .Patient required occasional cues for smaller bites and alternating solids/liquids . Review of a Speech Therapy Evaluation with treatment dates from 5/24/2022 through 6/22/2022, revealed results from a previous Modified Barium Swallow (MBS,a procedure to determine if food or liquid is entering the resident's lungs) that stated, Patient presents with severe oropharyngeal dysphagia .affecting the safety and efficiency of the swallow . Review of a Modified Barium Swallow performed on 6/9/2022 revealed the resident had an elevated risk of choking. Review of a Optum Comprehensive assessment dated [DATE] revealed a diagnosis of dysphagia with a plan to continue to monitor for coughing or choking with meals. Review of a progress note dated 11/15/2022 at 11:04 PM stated in part, at 9pm, resident found deceased . time of death 9:10pm. found with half eaten sandwich in mouth. upon cleaning mouth,dentures pulled out of back of mouth or throat by cna [certified nursing assistant] . During a surveyor interview on 11/21/2022 at 10:23 AM with CNA, Staff A she revealed that she gave the resident a tuna sandwich while s/he was in bed between 7:00 PM and 7:30 PM and did not return to check on him/her. Additionally, she revealed that she was unaware the resident should have been out of bed to eat and that she gives him/her a sandwich in bed often without any supervision. During a surveyor interview on 11/21/2022 at 10:30 AM with the Rehab Director she revealed that the resident had a history of being anxious while eating and would over stuff his/her mouth while eating. She further revealed that she would expect the nursing staff to get the resident out of bed to eat and that she would not recommend anyone be given food while in bed and then not checked on for 2 hours. During a surveyor interview on 11/21/2022 at 10:07 AM with Registered Nurse (RN), Staff B she revealed that one of the CNA's gave the resident a sandwich during the evening snack pass at approximately 7:30 PM. Additionally, she revealed that at approximately 9:00 PM she went into the resident's room to administer the roommate medication. She noted the resident appeared gray and ashen and could see part of a sandwich in his/her mouth. Additionally, she indicated that the resident was not breathing. Staff B indicated that was aware the resident had a history of choking and an order to be out of bed for food intake. Additionally she acknowledged the resident was not provided with supervision while eating in bed on 11/15/2022. During a surveyor interview on 11/22/2022 at 3:18 PM with CNA, Staff C, she revealed that she removed large amounts of a sandwich from the resident's mouth and his/her bottom dentures from his/her throat. Additionally, she acknowledged that she was aware the resident required to be out of bed and should be supervised for food intake and that s/he was not out of bed or supervised while eating on the night that s/he died. During a surveyor interview on 11/21/2022 at 12:17 PM, with the Director of Nursing Services she was unable to provide evidence that the resident had been out of bed and adequately supervised while eating to prevent an accident, although resident had a significant history of choking.

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 F0577 (Tag F0577)

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 post the results of the most recent survey of the facility conducted by Federal or...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to post the results of the most recent survey of the facility conducted by Federal or State surveyors. Findings are as follows: Record review revealed the most recent survey conducted at the facility was a Recertification Survey on 10/28/2022. Additionally, Complaint/Incident Investigation Surveys were conducted on 3/31/2022, 6/29/2022, 7/25/2022, 9/6/2022 and revisit surveys were conducted on 8/4/2022, 8/18/2022, and 9/26/2022. Record review of the facility's binder titled, Most Recent Facility Survey, failed to reveal evidence that the survey results for the above-mentioned dates were in the binder. During a surveyor interview on 11/25/2022 at approximately 10:30 AM with the Administrator and the Director of Nursing Services, they acknowledged the above-mentioned surveys were not included in the facility posted binder of the most recent surveys.

Oct 2022 10 deficiencies 1 IJ (1 affecting multiple)

CRITICAL (K)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Infection Control (Tag F0880)

Someone could have died · This affected multiple residents

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to prevent and contain the potential spread and transmission of COVID-19 in relation t...

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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to prevent and contain the potential spread and transmission of COVID-19 in relation to isolation and empiric transmission-based precautions for Residents, ID #s 8, 11, 25, 32, 48, 76, 85, and 241. Additionally, the facility failed to ensure appropriate personal protective equipment (PPE) is worn while caring for residents on transmission-based precautions for two staff observed, Nursing Assistant (NA), Staff J and Licensed Practical Nurse (LPN), Staff B. Furthermore, the facility failed to provide a sanitary environment relative to blood glucose monitoring for 3 of 3 residents observed during the medication administration task, Resident ID #s 50, 57, and 79. Findings are as follows: According to the COVID-19 guidance for Rhode Island Nursing Homes dated 10/12/2022 states in part, .Isolation [separates sick people with a contagious disease from people who are not sick] starts on the first day of symptoms or on the day of a positive test if there are no symptoms .Residents .isolate at least 10 full days since the date of their first positive test .Empiric transmission-based precautions [precautions includes the use of gown, gloves, goggles or face shield, and N95 mask] may be considered after close contact when a resident .unable to be tested or wear source control [PPE] for 10 full days following exposure .Resides on a unit experiencing ongoing COVID-19 transmission that has not been .controlled with initial interventions .If empiric transmission-based precautions are used, residents should quarantine and wear source .control around others until COVID-19 infection is ruled out. Empiric transmission-based precautions .for residents may be discontinued after .10 full days if they don't develop symptoms OR .7 full days following exposure if they test negative on 3 consecutive tests . 1. Record review revealed Resident ID #8 tested positive for COVID-19 on 10/20/2022 and s/he was within the recommended 10-day isolation period. Additional record review reveals the resident requires the physical assistance of one staff member and utilizes a walker to ambulate with staff supervision. Record review revealed Resident ID #241 tested positive for COVID-19 on 10/20/2022 and s/he was within the recommended 10-day isolation period. Additional record review reveals the resident requires the assistance of two plus staff members for locomotion and utilizes a wheelchair for mobility. Record review revealed Resident ID #s 32 and 85 were on COVID-19 Empiric transmission-based precautions (quarantine) related to a COVID-19 close contact exposure, these residents are roommates of Resident ID #s 8 and 241. During continuous surveyor observation of the Lily Unit's dining/activities area on 10/24/2022 between 12:17 PM and 1:30 PM, Resident ID #s 241 and 8, COVID-19 positive residents, were observed sitting in the dining/activities area without face masks on, waiting for the lunch meal to be served. Additionally, Resident ID #8 was noted to be coughing. Furthermore, Resident ID #s 32 and 85, residents on COVID-19 empiric transmission-based precautions, were also in the dining room without face masks on. In addition to these residents, there were approximately 20 COVID-19 negative residents observed in the dining/activities area, sitting, and wandering, without face masks on. Additionally, there were three NA's, one of which was Staff K, and one LPN, Staff H, observed to be going in and out of the dining/activities area, initially transporting residents into the area to prepare for lunch service, delivering lunch trays from the dietary trucks and then assisting with feeding of the residents when indicated. Further observation failed to reveal evidence that staff had made any attempts to prevent the negative and positive residents from coming into close contact with each other. Furthermore, staff failed to encourage any of the residents in the dining/activities area to wear face masks or maintain social distancing. During the above observation, at 1:07 PM, Resident ID #48, a COVID-19 negative resident, approached Resident ID #8, a COVID-19 positive resident, and picked up his/her cup of red liquid and drank from that cup. Resident ID #48 then attempted to pick up Resident ID #8's half-eaten sandwich when Staff K intervened and removed Resident ID #8's lunch tray. Staff K continued to gather other residents lunch trays and failed to direct or assist Resident ID #48 to perform hand hygiene. Resident ID #48 returned to the area where Resident ID #8 was seated and was then observed touching a bedside table and walker that was located directly next to Resident ID #8. During an additional surveyor observation on 10/24/2022 at approximately 2:20 PM, Staff K was observed transporting Resident ID #241, a COVID-19 positive resident, from the back of the dining/activities area, past approximately 20 COVID-19 negative residents, while Resident ID #241 was wearing his/her face mask below his/her chin. During an interview with Staff K on 10/24/2022 at approximately 2:30 PM, she acknowledged that Resident ID #48, the COVID-19 negative resident, consumed fluids from the cup of Resident ID #8, a COVID-19 positive resident, during the lunch meal that day. Additionally, she indicated that she did not assist Resident ID #48 with hand hygiene after s/he was observed touching the bedside table, lunch tray and walker that were located directly next to Resident ID #8. She further revealed that she was aware that Resident ID #241 had tested positive for COVID-19 and that she had transported the resident through the dining/activities area while his/her mask was around his/her chin within 6-feet of other residents, that were COVID-19 negative. During a surveyor interview on 10/24/2022 at 2:53 PM with LPN, Staff H, she indicated that she was aware that COVID-19 positive and COVID-19 negative residents should be kept isolated from one another. Additionally, she indicated her expectations are that staff are to assist residents with proper positioning of their face masks, to ensure their nose and mouths are covered. 2. Record review revealed a nursing progress note dated 10/25/2022 at 5:35 AM indicated that Resident ID #25 was sent to the emergency room and had returned to the facility at 5:00 AM from the hospital after being diagnosed at the hospital with a urinary tract infection and COVID-19. Further review of this progress notes indicates that Resident ID #25 was placed on precautions. During a surveyor observation of the Lily Unit dining/activities area on 10/25/2022 at 11:25 AM, revealed Resident ID #25, was observed sitting in the area wearing his/her face mask under his/her chin. Additionally, Resident ID #85, who was on empiric transmission-based precautions due his/her roommate testing positive for COVID-19, was also in the dining/activities area wearing his/her face mask under his/her chin. Additionally, there were approximately 20 COVID-19 negative residents sitting and wandering in the room without face masks on. During a surveyor interview on 10/25/2022 at 11:31 AM, with Unit Manager, LPN, Staff F, he acknowledged that residents who were on empiric transmission-based precautions and who have tested positive for COVID-19 were co-mingling with COVID-19 negative residents in the dining/activities area room without appropriate PPE. 3. According to the Rhode Island Department of Health guidance dated 10/12/2022, titled, COVID-19 Information for Nursing Homes, states in part, .All healthcare settings, such as nursing homes, should use the statewide community transmission rate to guide decisions about extra precautions related to infection prevention and control practices .during high community transmission (greater than or equal to 100/100,000 people) or outbreaks . Review of the Rhode Island Department of Health's COVID-19 Data Response Portal revealed the community transmission rate was high during the week of 10/24/2022. During a surveyor observation on 10/26/2022 at 11:42 AM in the presence of the Infection Control Nurse revealed Hospice NA, Staff J, wearing a surgical mask in the Lily unit kitchenette. Additionally, Resident ID #11 was in the kitchenette wearing his/her mask below the chin. Immediately following the above observation Staff J was observed transporting the resident out of the kitchenette and down the hallway without wearing proper PPE until the surveyor brought it to her attention. During a surveyor interview on 10/26/2022 at approximately 11:45 AM Staff J indicated she had been to multiple units in the facility visiting other residents and was never informed of the PPE that was required to be worn in the facility. During a surveyor interview on 10/26/2022 at 11:52 AM with the Infection Control Nurse, she acknowledged that she failed to ensure that all contracted staff on the COVID-19 positive unit were wearing the appropriate PPE as required. 4. Record review of a community reported complaint submitted to the Rhode Island Department of Health on 10/28/2022, the day after the survey team had exited the facility, alleges that COVID-19 positive residents are in the activity/dining area of the Lily unit co-mingling with COVID-19 negative residents without proper PPE. After this State Agency received this complaint a member of the survey team returned to the facility. A surveyor observation on 10/28/2022 at approximately 12:45 PM of the Lily Unit, revealed Resident ID #25, a COVID-19 positive resident, co-mingling with COVID-19 negative residents in the dining room, with his/her face mask below his/her nose and chin. Although at this time staff was observed to be directed Resident ID #25 to reposition his/her face mask. Record review revealed a care plan for the resident dated 10/25/2022 that states in part, .If resident comes out of room redirect back to room .and away from non-positive resident . During additional surveyor observations on 10/28/2022 at 1:20 PM and 1:34 PM revealed Resident ID #25 sitting at a table in the dining/activity area room with a COVID-19 negative resident, Resident ID #76, both residents were wearing their masks below their chins. Additionally, Resident ID #25 was observed to cough without wearing his/her mask at 1:54 PM. During a surveyor interview with the Infection Control Nurse immediately following the above-mentioned observations, she acknowledged that Resident ID #'s 25 and 76 were not wearing their masks properly or social distancing. 5. Review of the facility policy titled, Cleaning and Disinfecting dated 10/24/2022, states in part, .reusable medical equipment is cleaned and disinfected appropriately .PRACTICE STANDARDS .Non-critical items are objects that do not come into contact with mucus membranes, but do come into contact with intact skin ( .glucose meters [a small, portable machine used by people with diabetes to check their blood sugar levels after pricking the skin] .). These items require cleaning between patient use . During a surveyor observation of the medication administration task/glucose monitoring on 10/25/2022 with LPN, Staff B revealed the following: - 11:33 AM, Staff B was observed obtaining the blood sugar for Resident ID #50. She failed to clean/disinfect the glucometer after use. -11:45 AM, Staff B was observed obtaining the blood sugar for Resident ID #79. She failed to clean/disinfect the glucometer before and after use. -12:26 PM, Staff B was observed obtaining the blood sugar for Resident ID #57. Staff B failed to clean/disinfect the glucometer before use. During a surveyor interview on 10/25/2022 at 12:29 PM with Staff B, she acknowledged that she did not clean the glucometer per facility policy. Additionally, she indicated that she was not aware the glucometer is to be cleaned between each resident. During a surveyor interview on 10/27/2022 at approximately 12:30 PM with the Regional Clinical Director, she indicated that her expectation is for the nurse to clean/disinfect the glucometer between each resident. 6. Review of a facility policy titled, Contact Precautions revised 11/15/2021, states in part, .Contact Precautions will be used for diseases transmitted by direct or indirect contact with the patient or the patient's environment .Staff must use barrier precautions when entering the room .Wear gown and gloves . Record review revealed Resident ID #39 was diagnosed with Varicella zoster on 10/25/2022. During a surveyor observation on 10/26/2022 at 10:40 AM of the signage outside of Resident ID #39's room indicated a mask, gown, and gloves should be worn when entering the room. Staff B was observed in Resident ID #39's room obtaining his/her blood pressure without wearing a gown. During a surveyor observation on 10/26/2022 at 10:51 AM, Staff B was observed in the resident's room administering medication with just a mask on, no gloves or gown. She remained in the resident's room without the appropriate PPE on until 10:55 AM. During a surveyor interview with Staff B on 10/26/2022 at 10:56 AM, she acknowledged she was not wearing the appropriate PPE per the signage on the door. During a surveyor interview with the Infection Control Nurse on 10/27/2022 at 10:08 AM, she indicated that she expects staff to wear PPE as stated on the signage outside of the resident's room.

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 meet professional standards of quality relative to physician's orders for 1 of 1 residents reviewed, Resi...

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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 physician's orders for 1 of 1 residents reviewed, Resident ID #39. Findings are as follows: Review of a facility Policy titled, Skin Integrity and Wound Management states in part, .To provide safe and effective care to promote optimal skin health .and promote healing .PRACTICE STANDARDS .4. Identify patient's skin integrity status and need for .treatment interventions through .assessment .5. The nursing assistant will observe skin daily and report any changes or concerns to the nurse .6. The licensed nurse will .Evaluate any reported or suspected skin changes .Notify physician/APP [advanced practice provider] to obtain orders . Record review revealed that the resident was admitted to the facility in February of 2021. S/he has diagnoses including, but not limited to, breast cancer, muscle weakness, and congestive heart failure. During a surveyor observation on 10/25/2022 at 9:42 AM, with Nursing Assistant, Staff A and the resident the surveyor heard the resident telling Staff A that s/he had a rash on his/her back and was requesting for the nurse to see the rash. Additionally, the surveyor the observed Staff A applying a clear ointment to the rash on the resident's back. During a surveyor interview with Staff A immediately following the observation, she revealed she was unsure of what the ointment was that she applied to the residents back. She stated, I don't know .the nurse gave it to me to put on. During a surveyor interview with Licensed Practical Nurse, Staff B on 10/25/2022 at 12:22 PM, she acknowledged that the resident had a rash on his/her left side of his/her back and that she instructed Staff A to apply house stock barrier ointment (Hydrophor). Record review failed to reveal evidence of a physician's order for Hydrophor ointment. Additional record review revealed a progress note authored by Nurse Practitioner (NP), Staff C dated 10/25/2022 at 4:49 PM, indicating that she diagnosed the rash on the resident's left back as Varicella zoster (also known as shingles - a contagious viral infection that causes a painful rash) and treated with Valtrex 1 gram for 7 days along with Benadryl 25 mg (milligrams) once a day. During a surveyor interview with Regional Nurse, Staff D, on 10/27/2022 at 9:35 AM she indicated that her expectation would be to obtain a physician's order prior to initiating treatment of the rash. During a surveyor interview with Staff C on 10/27/2022 at 11:24 AM, she indicated her expectation is that nursing would obtain an order prior to initiating treatment.

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 ensure that residents receive tre...

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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 a physician's plan of care for 1 of 1 resident that expired in the facility, Resident ID #89. Record review revealed the resident was admitted to the facility in July of 2022 with diagnoses including, but not limited to, abdominal aortic aneurysm (enlarged area in the lower part of the major vessel that supplies blood to the body) without rupture and systolic congestive heart failure. Record review revealed a history and physical note dated, [DATE] at 11:13 AM, that states in part, .Plan: AKI [acute kidney injury] - Pt[patient] with elevated BUN/Cr [Blood urea nitrogen/Creatine, a test to monitor kidney function] on initial presentation, will recheck labs on Wednesday [[DATE]] . Record review of a progress note [DATE] revealed in part, .8:20am, pt [patient] found in an unresponsive state, attempt to rouse, sternal rub not successful, called the supervisor and other Nurses, started CPR [cardiopulmonary resuscitation] and called 911. Rescue team arrived and took over before transferring to .Hospital . Further record review revealed a progress note dated [DATE] at 6:34 PM states, expired [name redacted] hospital. Record review of a physician's order dated [DATE] states, IF WEIGHT INCREASES BY 2 LBS [pounds] IN 24 HOURS OR 5 LBS IN 1 WEEK, UPDATE MD [physician] FOR FURTHER ORDERS. every shift for HEART FAILURE Record review of a document titled Blood Pressure Summary for July of 2022, revealed the resident had an abnormal blood pressure documented as 70/40 (A normal reading would be any blood pressure below 120/80 and above 90/60 in an adult) on [DATE] at 6:11 AM. Further record review revealed that the blood pressure was not reassessed until approximately 19 hours later. Furthermore, the record failed to reveal evidence that the MD was notified of the resident's abnormal blood pressure. Further record review revealed the following: - the labs were not obtained as ordered on [DATE] - the resident was not weighed on [DATE], [DATE], [DATE], [DATE] and [DATE]. Additionally, that the resident had a 3.2-pound weight gain from [DATE] to [DATE] and the Nurse Practitioner (NP) or the Medical Director were not notified of the missed weights, the weight gain of 3.2 pounds or the labs not being obtained. During a surveyor interview on [DATE] at 11:56 AM, with the Nurse Practitioner, Staff C and the Medical Director, they revealed that they would have expected to have been notified of the resident blood pressure of 70/40. Additionally, they revealed that they would have expected the labs to have been obtained and reported. Furthermore, they revealed they would expect the facility to follow the physician's orders. During a surveyor interview on [DATE] at 11:58 AM, with the Acting Director of Nursing Services and the Regional Clinical Director, they were unable to provide evidence that the labs were obtained as ordered on [DATE], that the blood pressure of 70/40 had reported or that the facility followed MD orders for daily weights.

CONCERN (D)

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

Accident Prevention (Tag F0689)

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 a residents environment remains as free from accident hazard...

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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 a residents environment remains as free from accident hazards as possible for 3 of 31 residents who reside on a secured memory care unit relative to disposable razor storage, Resident ID #'s 64, 73 and 74. Findings are as follows: 1a. Record review for Resident ID #64 revealed that s/he was admitted to the facility in April of 2020 with diagnoses including but not limited to Alzheimer's disease and dementia. S/he is care planned for lack of safety awareness, poor impulse control and wandering. Record review of the 9/30/2022 Quarterly Minimum Data Set (MDS) Assessment revealed s/he has a BIMS (Brief Interview for Mental Status) score of 8 out of 15, indicating moderately impaired cognition. Record review for Resident ID #73 revealed that s/he was admitted to the facility in November of 2018 with diagnoses including but not limited to Alzheimer's disease. S/he is care planned for lack of safety awareness. Record review of the 7/29/2022 Quarterly MDS Assessment revealed s/he has poor decision making and requires ques and supervision for tasks of daily life. Surveyor observations during the survey revealed both Resident ID #'s 64 and 73 were ambulating independently around the unit. During surveyor observations of Resident ID #'s 64 and 73's bathroom on 10/25/2022 at 9:16 AM, revealed one disposable razor on the counter. During an interview on 10/25/2022 with Nursing Assistant, Staff E at 9:27 AM, he acknowledged that the razor should not be stored in the resident's room. 1b. Record review revealed Resident ID #74 was admitted to the facility in May of 2022 with diagnoses including but not limited to vascular dementia. S/he is care planned for lack of safety awareness. Record review of the 10/19/2022 Quarterly MDS Assessment revealed s/he has a BIMS score of 10 out of 15, indicating moderately impaired cognition. Surveyor observation of Resident ID #74's bathroom on 10/25/2022 at approximately 9:45 AM, revealed one disposable razor without a safety cover stored in a wash basin on the counter. Immediately following this observation an interview was conducted with Staff E, he acknowledged that the razor should not be stored in the resident's bathroom. During an interview with Licensed Practical Nurse, Staff F on 10/25/2022 at approximately 10:00 AM, he revealed that his expectation is that razors should be removed from the resident's rooms immediately after use and properly disposed of.

CONCERN (D)

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

Tube Feeding (Tag F0693)

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 ensure that residents that are fed through a feeding tube receive the appropriate t...

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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 that are fed through a feeding tube receive the appropriate treatment and services to prevent complications for 1 of 1 residents reviewed receiving nutrition via a feeding tube, Resident ID #49. Findings are as follows: Review of the facility policy titled, Medication Administration: Enteral states in part, Allow medications to flow down the syringe via gravity .Do not push medications through the tube . Record review revealed the resident was admitted to the facility in May of 2021 with diagnoses including but not limited to cerebral infarction (stroke) and dysphagia (difficulty swallowing). Record review revealed a physician's order dated 12/9/2021, Enteral Feed order: Osmolite 1.5 at 45 mL/hr (milliliters/hour) for 20 hours, 2:00 PM - 10:00 AM. During surveyor observation on 10/25/2022 at 12:10 PM, revealed Licensed Practical Nurse, Staff B push medications and a water flush through the tube and not to gravity. During a surveyor interview with Staff B on 10/25/2022, immediately following the above observation, she acknowledged that she did not administer the medication or water flush to gravity. During a surveyor interview with the Regional Clinical Director on 10/27/2022 at 12:30 PM, she indicated her expectation is for the nurses to administer medications and feeding tube water flushes via gravity per facility policy.

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, resident, and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis receive services, consistent with professional stan...

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Based on record review, resident, and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis receive services, consistent with professional standards of practice, for 1 of 1 residents reviewed for dialysis, Resident ID #50. Findings are as follows: According to the Illustrated Manual of Nursing Practice, 2nd, 1994, .after completion of hemo-dialysis, monitor the access device for bleeding .Assess circulation at the access site at least four times daily by auscultating for bruit [audible vascular sound associated with turbulent blood flow] and palpating for thrill [vibration felt of blood flow] . Review of a facility policy titled, Dialysis: Hemodialysis [treatment to filter wastes and water from your blood] (HD) Provided by a Certified Dialysis Facility states in part, Patients who require HD services receive care consistent with professional standards of practice .Professional standards of practice include .Ongoing assessment of the patient's condition and monitoring for complications before and after HD .After receiving dialysis, Center staff must provide monitoring and documentation of .The patient's vascular access site(s) to observe for bleeding or other complications . Record review revealed the resident was admitted to the facility in September of 2022 with diagnosis including but not limited to, end stage renal (kidney) disease. Record review of an admission Minimum Data Set assessment dated , 9/19/2022, revealed a Brief Interview for Mental Status score of 14 out of 15 indicating his/her cognition is intact. Further record review revealed a document titled Providence Access Care dated 10/6/2022, which indicates the resident's external catheter for dialysis access was removed on 10/6/2022. The form states in part, .Left Upper Arm AV Fistula [connection that's made between an artery and a vein for dialysis access] .access is ready to use at hemodialysis . Further record review failed to reveal evidence of any assessments or monitoring of the resident's left upper arm fistula for bruit and thrill. During a surveyor interview on 10/27/2022 at 12:15 PM, with the resident s/he indicated that the external catheter was removed a few weeks ago, and that the dialysis center accesses his/her left arm fistula for his/her dialysis treatments. During a surveyor interview with the Regional Clinical Director on 10/27/2022 at 12:31 PM, she indicated that her expectation is that the resident's upper left arm AV Fistula should be assessed and monitored per the policy.

CONCERN (D)

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

Deficiency F0805 (Tag F0805)

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 food prepared in a form designed to meet individual needs for 1 of 2 resid...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide food prepared in a form designed to meet individual needs for 1 of 2 residents reviewed, Resident ID #74. Findings are as follows: Record review revealed the resident was admitted to the facility in May of 2022 and re-admitted in August of 2022, with diagnoses to include but limited to, dysphagia (difficulty swallowing) and pneumonitis due to inhalation of food and vomit. Review of the record revealed a physician's order, dated 8/22/2022, .Regular/Liberalized diet, Dysphagia Puree texture, Thick Liquids-Honey Like/thick consistency . Surveyor observations on the following dates revealed the resident's fluids were not thickened to honey like thick consistency as ordered: -10/25/2022, breakfast and lunch meals -10/26/2022. breakfast and lunch meals -10/27/2022, breakfast During the breakfast observation on 10/27/2022 between 9:00 AM and 9:10 AM an interview was conducted with Nursing Assistant, Staff E, who was feeding the resident's roommate, he acknowledged the house supplement and the cup of coffee on the meal tray for Resident ID #74 were not honey thickened as ordered. Continued observation of the resident in the presence of the Licensed Practical Nurse, Staff H, revealed the resident was observed picking up the cup of house supplement that was not thickened as ordered, took a sip, then began to attempt to cough. S/he had difficulty breathing and his/her eyes began to water. The resident was able to cough after approximately 10-15 seconds then began spitting out the house supplement into a facecloth. During a surveyor interview immediately following the above observation with Staff H, she acknowledged the resident was coughing and choking after s/he drank the unthickened house supplement. Additionally, she revealed that she would expect the fluids to be honey thickened per the physician's order. During an interview with the Medical Director on 10/27/2022 at 11:40 AM, she indicated that she was not aware that the resident was not receiving the honey thickened liquids as ordered.

CONCERN (E)

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

Unnecessary Medications (Tag F0759)

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 ensure that each resident's medication regimen is free from medication error rates...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that each resident's medication regimen is free from medication error rates of 5% or greater. Based on 26 opportunities for error observed during the medication administration task, there were 5 errors resulting in a 19.23% error rate involving Resident ID #'s 17, 49 and 68. Findings are as follows: Review of the facility's policy titled, Medication Administration: Enteral [involves administering medication and nutrition directly into the stomach via an external tube] states in part, .Prepare each medication in individual medicine cups .Administer medications individually. (A prescriber's order must be obtained to combine multiple crushed medications for the same administration. If there is no order to combine, medications must be administered one at a time) . 1. Record review revealed Resident ID #49 had the following physician orders: -8/16/2022 Apixaban Tablet 5 milligrams (mg) Give 5 mg via G-tube (a gastrostomy tube inserted through the belly that brings nutrition and medication directly to the stomach). -5/15/2021 Furosemide Tablet 20 MG Give 20 mg via G - Tube in the morning -10/11/2022 Zoloft Oral Tablet 50 MG Give 1 tablet via PEG - Tube (G- tube) one time a day During the medication administration task on 10/25/2022 at 12:10 PM, with Licensed Practical Nurse (LPN), Staff B, she combined and crushed the Apixaban, Furosemide, and Zoloft tablets together and administered them via the resident's G-tube simultaneously. During a surveyor interview with Staff B on 10/25/2022 at 12:22 PM, she acknowledged that she combined the above medications and administered them simultaneously. During a surveyor interview with Regional Clinical Director on 10/27/2022 at 12:30 PM, she indicated that she expects the nurses to crush and administer medications individually according to policy. 2. Record review revealed Resident ID #17 had a physician's order with start date of 2/7/2022 for Carbidopa-Levodopa Tablet 25-100 MG Give 2 tablet by mouth five times a day for parkinson's disease. During a surveyor observation of the medication administration task on 10/24/2022 at 10:35 AM with Staff B, she administered one tablet of Carbidopa-Levodopa 25 - 100 MG to the resident instead of the ordered two tablets. During a surveyor interview with Staff B on 10/24/2022 at 2:02 PM, she acknowledged that she did not follow the physician's order. 3. Record review revealed Resident ID #68 had a physician's order dated 9/20/2022 for Risperidone Oral Tablet 0.5 MG Give 1.5 mg by mouth two times a day. During the medication administration task on 10/24/2022 at approximately 10:45 AM with Staff B she administered one tablet of Risperidone 0.5 mg to the resident, instead of the 1.5 mg as ordered. During surveyor interview with Staff B on 10/24/2022 at 2:02 PM, she acknowledged that she gave the resident one tablet of Risperidone 0.5 mg. During a surveyor interview with the Administrator on 10/27/2022 at approximately 12:30 PM, she was unable to provide evidence that each resident's medication regimen is free from medication error rates of 5% or greater.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

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 store and label drugs and biologicals in accordance with currently accepted profes...

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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 biologicals in accordance with currently accepted professional principles for 4 of 5 medication carts reviewed. Findings are as follows: 1) During a surveyor observation of the [NAME] unit medication cart on 10/24/2022 at 11:50 AM, in the presence of Certified Medication Technician (CMT), Staff I, revealed the following: -Spiriva 2.5 micrograms (mcg) with a label stating use by date 1/12/2022. -Bottle of Vitamin D 10 mcg with expiration date of 9/2022 -Trelegy Ellipta 200-625 milligrams (mg) with no date listed when opened. Manufacturer's instructions state, Date when the foil tray is opened and discard after 6 weeks or when the dose counter reads zero, whichever comes first. During a surveyor interview with Staff I on 10/24/2022 immediately following the above observation, she acknowledged the findings. Additionally, she indicated that the Spiriva inhaler was brought in by the resident's family. She acknowledged placing it in the medication cart despite it having a use by date listed of 1/12/2022 listed on it. 2) During a surveyor observation on 10/24/2022 at 2:20 PM of the Buttercup medication cart in the presence of Licensed Practical Nurse (LPN), Staff B, revealed the following: -Latanoprost 0.0005% bottle in the medication cart unopened. Manufacturer's instructions state, Store in the refrigerator at 36 to 46 degrees Fahrenheit until ready to use . -Latanoprost 0.0005% bottle open and undated. Manufacturer's instructions state, Date when opened and discard after 6 weeks. -Ketotifen Fumarate 0.025% bottle opened and undated. Pharmacy medication storage instructions for ophthalmic products indicate, date when opened and discard unused portion after 28 days . -Timolol 0.5 % bottle opened and undated. Manufacturer's instructions states, After opening foil wrapper, use within one month. -Breo Ellipta 30 dose inhaler, opened and undated with 23 doses remaining. Pharmacy's instructions state in part, .Date when opening the foil tray and discard after 6 weeks or when the dose counter reads '0', whichever comes first. -Spiriva 0.5 mcg/actuation, three boxes with expiration dates of 7/8/2022. During a surveyor interview with Staff B on 10/24/2022 at 2:35 PM, she acknowledged the above findings. 3) During a surveyor observation of the Lily unit medication cart on 10/26/2022 at 10:19 AM, in the presence of LPN, Staff F, revealed the following: -Aspirin 81 mg bottle with no visible expiration date. During a surveyor interview with Staff F at the time of the observation on 10/26/2022, he acknowledged there was no visible expiration date on the bottle. 4) During a surveyor observation of the Lily Unit nurse medication cart on 10/26/2022 at 10:33 AM, in the presence of Staff F revealed the following: -Bottle of Aspercreme with lidocaine, opened with an expiration date of 4/2022 -Ketoconazole shampoo 2%, pharmacy label illegible -Providine iodine solution bottle, opened with an expiration date 12/2020 During a surveyor interview on 10/26/2022 immediately following the above observations with Staff F, he acknowledged the findings. During a surveyor interview on 10/27/2022 at approximately 12:30 PM, with the Administrator and Regional Clinical Director, they were unable to provide evidence that the above medications and biologicals were stored in accordance with currently accepted professional principles.

MINOR (C)

Minor Issue - procedural, no safety impact

Antibiotic Stewardship (Tag F0881)

Minor procedural issue · This affected most or all residents

Based on record review and staff interview, it has been determined that the facility failed to establish an Infection prevention and control program (IPCP) that must include, at a minimum, an antibiot...

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Based on record review and staff interview, it has been determined that the facility failed to establish an Infection prevention and control program (IPCP) that must include, at a minimum, an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. Findings are as follows: Review of the antibiotic stewardship monthly records failed to reveal documentation of tracking information for the months of July, August, September, and October 2022. During a surveyor interview on 10/27/2022 at 10:20 AM with the Infection Control Nurse, she acknowledged that she had not begun tracking this information for September and October 2022. Additionally, she was unable to provide evidence of a tracking system relative to antibiotic stewardship for July and August 2022, prior to her arrival.

Greenville Skilled Nursing and Rehabilitation

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The Ugly 51 deficiencies on record

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Greenville Skilled Nursing and Rehabilitation

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