What is Berkshire Place's CMS rating?

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

Does Berkshire Place have any serious inspection findings?

Yes, Berkshire Place has 3 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 53 total deficiencies from recent inspections.

What are the staffing levels at Berkshire Place?

Berkshire Place has a one-star staffing rating from CMS. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is Berkshire Place located?

Berkshire Place is located in Providence, RI. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does Berkshire Place have?

Berkshire Place has 220 certified beds.

Who owns Berkshire Place?

Berkshire Place is a for profit - limited liability company facility and is part of the GREEN TREE HEALTHCARE MANAGEMENT chain.

Is Berkshire Place safe?

Berkshire Place has documented safety concerns including 3 immediate jeopardy citations. Families should ask about corrective actions taken.

Was Berkshire Place ever fined?

Yes, Berkshire Place has been fined $263,402 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is Berkshire Place on any federal watch list?

No, Berkshire Place 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 Berkshire Place?

Medicare inspectors have found 53 deficiencies at Berkshire Place: 3 critical, 6 serious, 44 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting Berkshire Place?

Families visiting Berkshire Place 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 Berkshire Place compare to other nursing homes?

Berkshire Place 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.

Berkshire Place | 0/100 (Grade F)

May 2025 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

Report Alleged Abuse (Tag F0609)

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 all alleged violation...

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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 all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or, no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the local state agency (Rhode Island Department of Health, RIDOH), in accordance with State law, for 1 of 2 residents reviewed for allegations of abuse, Resident ID #1. Findings are as follows: Review of a facility's policy titled Abuse prohibition dated 10/31/2022 states in part, .Any instance of actual or suspected abuse .must be reported immediately to the DNS [Director of Nursing] .an incident report is to be filled out. The Department of Health will be contacted of allegations of abuse . Review of a community reported complaint submitted to RIDOH dated 5/19/2025 alleged, Resident ID #1's continuity of care form that was sent with him/her to a facility from the hospital revealed that s/he had allegedly killed someone at Berkshire Place. Record review revealed the resident was readmitted to the facility in December of 2021 with diagnoses including, but not limited to, dementia and anxiety disorder. Record review of a Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating the resident's cognition is intact. Record review of a progress note dated 3/13/2025 at 12:30 PM revealed, Resident ID #1 walked up to another resident and threatened to physically harm that resident. Further record review of this progress note revealed that Resident ID #1 was sent to the emergency room for an evaluation and was admitted . During a surveyor interview on 5/19/2025 at 9:33 AM with the Director of Nursing services (DNS), she acknowledged that the resident threatened to physically harm another resident on 3/13/2025 and s/he was sent to the hospital for an evaluation. Additionally, the DNS acknowledged that she did not repot this incident to RIDOH, as required.

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 F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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

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Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principles for 2 of 4 medication carts observed. Findings are as follows: Review of a facility policy titled Medication Storage dated January 2023 states in part, Medications and biological's are stored properly, following manufacturers or provider pharmacy recommendations to maintain their integrity .Medications requiring refrigeration are kept in a refrigerator . Review of a community reported complaint submitted to the Rhode Island Department of Health on 5/19/2025, alleged that medications are not stored and administered correctly to residents. 1. A surveyor observation on 5/20/2025 at 9:07 AM of the second floor [NAME] Medication Cart in the presence of Certified Medication Technician (CMT), Staff A, revealed two Trelegy Ellipta inhalers opened and not dated. Manufacturer's instructions indicate to discard the inhalers 6 weeks after opening. During a surveyor interview immediately following the above-mentioned observation with Staff A, she acknowledged the inhalers were opened and not dated. 2. A surveyor observation on 5/20/2025 at 9:17 AM of the second-floor nurse medication cart in the presence of Licensed Practical Nurse, Staff B, revealed the following: - Morphine Sulfate 100 milligram (mg)/5 millimeter (ml) opened and not dated. Manufacturer's instructions indicate to discard this medication 90 days after opening. - Lorazepam Intensol oral suspension 2 mg/ml opened and not dated. Manufacturer and pharmacy label on the packet of this medication indicated to refrigerate this medication and to discard it after 90 days. During a surveyor interview immediately following the above-mentioned observation with Staff B, she acknowledged the Morphine Sulfate and the Lorazepam Intensol were opened and not dated. Additionally, Staff B acknowledged the Lorazepam was not stored in the refrigerator, as required. 3. A surveyor observation on 5/20/2025 at 9:30 AM of the first-floor nurse medication cart in the presence of a Registered Nurse, Staff C, revealed two bottles of Morphine Sulfate 100 mg/5 ml opened and not dated. Manufacturer's instructions indicate to discard this medication 90 days after opening. During a surveyor interview immediately following the above-mentioned observation with Staff C, she was unable to provide evidence the Morphine Sulfate bottles were stored appropriately, as required. During a surveyor interview on 5/20/2025 at 1:08 PM with the Director of Nursing Services, she indicated that she would expect the above-mentioned medications to be dated when opened and would expect the Lorazepam to be refrigerated, as required.

Mar 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure a resident receives adequate supervision to prevent accidents for 1 of 1 resident reviewed who successfully eloped from the facility, Resident ID #2. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 3/27/2025, alleges that Resident ID #2 eloped from the facility on 2/3/2025, following a snowstorm. Additionally, upon return, the facility failed to perform an elopement assessment and had initially stated that the resident left against medical advice (AMA). Record review of a facility policy dated 11/1/2022 titled, Elopement Assessments states in part, .It is the policy of this facility to maintain a safe and secure environment for all residents. In order to achieve this goal residents who are at risk of wandering/elopement need to be identified and a care plan developed with interventions to minimize or eliminate the risk .an elopement assessment is to be performed whenever a resident exhibits a change in behaviors which signals an increased risk, such as verbalizing a wish to leave the building . Record review revealed the resident was admitted to the facility in January of 2025 with a diagnosis including, but not limited to, schizophrenia (a chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges). Review of an admission Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 9 out of 15, indicating moderately impaired cognition. Further review revealed the resident is dependent upon staff for dressing and requires supervision or touching assistance for ambulation. Record review of a document titled; Elopement Evaluation dated 1/22/2025 revealed the resident was not at risk for elopement. Record review revealed a physician order dated 1/22/2025 which indicated the resident may not go out on leave of absence. Record review of a document titled, Smoking Risk Assessment dated 2/12/2025 revealed that the resident requires supervision for smoking and that s/he is an elopement risk. Record review revealed the following progress notes: - 1/26/2025 at 2:57 PM, the resident was oriented to person only and s/he was confused. - 1/27/2025 at 9:00 AM, the resident continued to ask multiple staff when s/he was going home. -1/28/2025 at 5:41 AM, the resident has expressed a strong desire to return home and s/he ambulates independently without the use of an assistive device. - 2/3/2025 at 10:07 AM, the resident left the facility and took a bus to his/her previous residence, an Assisted Living Facility (ALF) in the community, approximately 2 miles away. Additionally, the note indicates that a call was received from the ALF to inform the facility that the resident was there. Transport was arranged and a staff member was sent to pick up the resident and return him/her back to the facility. - 2/4/2025 at 10:30 AM, the resident left the facility AMA on 2/3/2025. - 2/8/2025 at 8:00 AM, the resident continues on 1:1 status due to being an elopement risk. - 2/26/2025 at 3:51 PM, the resident is an elopement risk. Record review failed to reveal evidence that an elopement assessment had been performed, and a care plan was developed with interventions to minimize risks per facility policy following the resident's successful elopement from the facility. During a surveyor interview on 3/27/2025 at approximately 2:15 PM with the Director of Nursing Services, she revealed that on 2/3/2025, the resident left the faciity on his/her own accord and since s/he is alert and oriented, it was her interpretation that the resident had left AMA from the facility. However, she was unable to provide evidence of a completed AMA discharge form. She acknowledged that the resident had a BIMS score of 9 out of 15, indicating moderate cognitive impairment and that s/he has a physician order indicating that s/he may not go out on a leave of absence from the facility. Further, she was unable to provide evidence that an Elopement Evaluation had been completed after s/he left the facility unsupervised on 2/3/2025. During a surveyor interview on 3/27/2025 at 2:44 PM with the Administrator, she acknowledged that an AMA discharge documentation or assessments had not been performed. She further acknowledged that the progress notes indicated that the resident had eloped, and that an Elopement Evaluation had not been completed, a care plan had not been developed, and appropriate interventions were not in put in place for the resident per facility policy following the above-mentioned incident.

Jan 2025 3 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

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to notify the resident and the resident's representative(s) of a transfer or discharge and the reasons for t...

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Based on record review and staff interview, it has been determined that the facility failed to notify the resident and the resident's representative(s) of a transfer or discharge and the reasons for the move in writing and in a language and manner they understand for 1 of 1 resident who was transferred to the hospital and discharged from the facility, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to The Rhode Island Department of Health on 1/15/2025, alleged that Resident ID #1 was not permitted to return to the facility, and s/he was not given a 30 day notice, as required. Record review revealed that the resident was admitted to the facility in July of 2019 with diagnoses of violent behaviors and dementia. Record review revealed a Quarterly Minimum Data Set Assessment, dated 12/2024, revealed a Brief Interview for Mental Status Score could not be completed as the resident has severe cognitive impairment. Record review further revealed that s/he was transferred to the emergency room for evaluation following an alleged resident to resident interaction on 1/14/2025 at 1:32 PM. Further record review revealed that the resident was documented as being discharged from the facility on 1/14/2025. Record review failed to reveal evidence that the facility notified the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. During a surveyor interview with the Administrator and the Director Of Nursing on 1/17/2025 at approximately 1:10 PM, they were unable to provide evidence that the resident and the resident's representative(s) were notified of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. Cross Reference F 625 and F 626

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to provide evidence that written notification was provided to the resident or resident representative(s) reg...

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Based on record review and staff interview, it has been determined that the facility failed to provide evidence that written notification was provided to the resident or resident representative(s) regarding a bed hold. Additionally, at the time of transfer the facility failed to provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy for 1 of 1 resident who was transferred to the hospital, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to The Rhode Island Department of Health on 1/15/2025, alleged that Resident ID #1 was not permitted to return to the facility, and s/he was not given a 30 day notice, as required. Record review revealed that the resident was admitted to the facility in July of 2019 with diagnoses of violent behaviors and dementia. Record review revealed a Quarterly Minimum Data Set Assessment, dated 12/2024, revealed a Brief Interview for Mental Status Score could not be completed as the resident has severe cognitive impairment. Record review further revealed that s/he was transferred to the emergency room for evaluation following an alleged resident to resident interaction on 1/14/2025 at 1:32 PM. Further record review revealed that the resident was documented as being discharged from the facility on 1/14/2025. Record review failed to reveal evidence that written notification was provided to the resident or resident representative(s) regarding a bed hold that specifies the duration of the state bed-hold policy during which the resident is permitted to return and resume residence in the nursing facility, the reserve bed payment policy in the state plan and the nursing facility's policies regarding bed-hold periods. Additionally, record review failed to reveal evidence that at the time of resident's transfer from the facility that the resident and the resident representative(s) were provided with written notice of the duration of the bed-hold policy. During a surveyor interview with the Administrator and the Director of Nursing on 1/17/2025 at approximately 1:10 PM, they were unable to provide evidence that the facility provided written information to the resident or resident representative(s) regarding a bed hold. Additionally, they were unable to provide evidence that at the time of transfer the resident or the resident representative was provided with written notice of the duration of the bed-hold policy. Cross Reference F 623 and F 626

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 Transfer (Tag F0626)

Could have caused harm · This affected 1 resident

Based on surveyor observation, record review and staff interview, it has been determined that after a resident was transferred to the hospital, the facility failed to allow the resident to return to f...

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Based on surveyor observation, record review and staff interview, it has been determined that after a resident was transferred to the hospital, the facility failed to allow the resident to return to facility where s/he resided for several years for 1 of 1 resident reviewed who was transferred to the hospital, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to The Rhode Island Department of Health on 1/15/2025, alleged that Resident ID #1 was not permitted to return to the facility, and s/he was not given a 30 day notice, as required. Record review revealed that the resident was admitted to the facility in July of 2019 with diagnoses of violent behaviors and dementia. Record review further revealed that s/he was transferred to the emergency room for evaluation following an alleged resident to resident interaction on 1/14/2025 at 1:32 PM. Further record review revealed that the resident was documented as being discharged from the facility as of 1/14/2025. Record review failed to reveal evidence that the resident was allowed to return to the facility following a hospitalization or therapeutic leave. Surveyor observation on 1/17/2025 at 11:50 AM revealed the resident's room prior to his/her hospital transfer was vacant. During a surveyor interview with the Administrator and the Director of Nurses (DON) on 1/17/2025 at approximately 10:25 AM, they indicated that they sent the resident out to the hospital for a psychological evaluation due to his/her behaviors and that the hospital diagnosed the resident with Covid and a urinary tract infection (a urinary tract infection in the elderly population can commonly cause agitation). During a surveyor interview with the Administrator and the DON on 1/17/2025 at approximately 1:10 PM, they revealed that they are not allowing the resident to return to the facility. Cross Reference F 623 and F 625

Nov 2024 2 deficiencies

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 F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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

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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 provide food and drinks that are palatable, attractive, and at an appetizing temperature for 4 of 5 residents reviewed, Resident ID #s 2, 3, 4, and 5. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 11/4/2024 alleges concerns regarding hot food items that are being served cold and at an unappetizing temperature. Record review of the facility policy titled, Monitoring Food Temperatures for Meal Service revealed that food temperatures of hot foods on room trays at the point of service are preferred to be at 120 F (Fahrenheit) or greater to promote palatability for the resident. 1. Record review revealed Resident ID #2 was admitted to the facility in September of 2021 with a diagnosis including, but not limited to, type II diabetes mellitus. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. During a surveyor interview on 11/4/2024 at 12:15 PM with Resident ID #2, s/he revealed that hot food items are always cold and this has been an ongoing issue ever since s/he was admitted to the facility. 2. Record review revealed Resident ID #3 was admitted to the facility in October of 2024 with a diagnosis including, but not limited to, hypertension (high blood pressure). Review of an MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating intact cognition. During a surveyor interview on 11/4/2024 at 12:00 PM with Resident ID #3, s/he revealed that the food the facility has served him/her within the last week has been cold and not palatable. This has resulted in the resident opting to source meals from outside of the facility. 3. Record review revealed Resident ID #4 was readmitted to the facility in August of 2024 with a diagnosis including, but not limited to, depression. Review of an MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating intact cognition. During a surveyor interview on 11/6/2024 at 9:25 AM with Resident ID #4, s/he revealed that hot food items are served cold all the time and s/he has to microwave it every day. 4. Record review revealed Resident ID #5 was admitted to the facility in September of 2024 with a diagnosis including, but not limited to, gastro-esophageal reflux disease (condition when acid flows back from the stomach into the esophagus). Review of an MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15, indicating intact cognition. During a surveyor interview on 11/6/2024 at 9:36 AM with Resident ID #5, s/he revealed that the breakfast s/he was served this morning was not hot and that s/he refused to eat it. S/he has chosen to address the meal temperatures by heating his/her food personally. During a surveyor interview on 11/4/2024 at 12:22 PM with the Unit Manager, Staff A, a test tray was ordered to determine if the food temperature was above 120 F, per the facility policy. During a surveyor observation of the test tray on 11/4/2024 at 1:30 PM with Staff A, the following was observed: - mashed potatoes with a temperature of 112.7 F - chicken with a temperature of 106.1 F - vegetables with a temperature of 117.8 F During a surveyor interview following the above observation with Staff A, she revealed that she would expect the food temperatures to be closer to 135 F and acknowledged that the food failed to hold the temperature from the steamer. During a surveyor interview on 11/4/2024 at 1:25 PM with Resident ID #2, s/he revealed that the lunch that s/he just received was cold and needed to be reheated. During a surveyor interview on 11/4/2024 at 2:00 PM with the Food Service Director, she revealed that she would expect the food from the test tray to be at least 120 F or higher, per the facility policy.

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to prepare, store, and distribute food according to professional standards of food service safety, relative to 1 of 1 meal pass observed, and 1 of 2 observations of the main kitchen relative to use of hair restraints. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 11/4/2024 alleges concerns regarding hot food items that are being served cold and at an unappetizing temperature, and that staff members who help serve the food do not wear hairnets. 1. The [NAME] Food Code 2018 Edition 3-501.18 states in part, .the food shall have an initial temperature of 57 degrees C (Celsius),135 degrees F (Fahrenheit) when removed from hot holding temperature control . Record review of the facility policy titled, Monitoring Food Temperatures for Meal Service revealed that if the serving/holding temperature of a hot food item is not at 135 F or higher when checked prior to meal service, the item will be reheated to at least 165 F for a minimum of 15 seconds. During a surveyor observation of the steam table on 11/4/2024 at 12:52 PM, with Dietary Aide, Staff B, and Unit Manager, Staff A, revealed the following food temperatures while in the holding steam table: - Mashed potatoes with a temperature of 129.2 F - chicken with a temperature of 128.3 F - burger patties with temperatures of 125.4 F During a surveyor interview following the above observation with Staff B, she acknowledged that the above food items failed to meet the facility policy for holding temperatures of 135 to 145 F. Further observation failed to reveal evidence that the above food items were heated back to 165 F, per the facility policy. During a surveyor interview on 11/4/2024 at 2:00 PM with the Food Service Director (FSD), she acknowledged that she would expect the steam table to hold the food temperature to at least 135 F, and that Staff B should have reheated the food when it was identified to be below 135 F, per the facility policy. 2. The Rhode Island Food Code, 2018 Edition, section 2-402.11 states in part, .Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens . During surveyor observation of Dietary Aide, Staff C, in the main kitchen on 11/4/2024 at 1:40 PM, he was in the kitchen while food was being prepared and was handling equipment without wearing a hair restraint. During a surveyor interview following the above observation with Staff C, he revealed that it is the facility's policy for everyone to wear a hair restraint while in the kitchen. During a surveyor interview on 11/4/2024 at 2:00 PM with the FSD, she revealed that she would expect all staff to wear a hair restraint while working in the kitchen.

Oct 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

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 record review, staff, and resident interview, it has been determined that the facility failed to protect a resident's r...

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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 protect a resident's right to be free from abuse for 1 of 2 residents reviewed, Resident ID #2. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 10/7/2024 indicates, the facility became aware of an allegation made by Resident ID #1 who stated that on 10/6/2024 s/he was resting in his bed when Resident ID #2 entered his/her room and joined him/her in bed. Resident ID #1 denied making any advances toward Resident ID #2 at that time. Record review of a community reported complaint submitted to the Rhode Island Department of Health on 10/7/2024 alleges, Resident ID #1 had been sleeping in his/her bed when s/he was awoken by Resident ID #2 sitting on his/her face, fully clothed. Resident ID #1 stated that following the above-mentioned event s/he retaliated against Resident ID #2 by getting into his/her bed and touching his/her genitals. Record review for Resident ID #1 revealed that s/he was admitted to the facility in August of 2024 with diagnoses including, but not limited to, mild neurocognitive disorder, type 2 diabetes, and sepsis. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderately impaired cognition. Record review for Resident ID #2 revealed that s/he was admitted to the facility in July of 2019 with diagnoses including, but not limited to, dementia, schizophrenia, urinary tract infection, cognitive communication deficit, muscle weakness, and unsteadiness on feet. Review of a MDS assessment dated [DATE] revealed a BIMS score of 0 out of 15, indicating severely impaired cognition. A surveyor interview was attempted with Resident ID #2 on 10/8/2024 at approximately 8:50 AM but was unable to be conducted due to his/her severely impaired cognition. During a surveyor interview with the Assistant Administrator and the Director of Nurses (DON) on 10/7/2024 at approximately 2:40 PM, the DON revealed that she was made aware that Resident ID #1 had touched Resident ID #2's genital areas from another resident, Resident ID #4, who had witnessed the incident. Additionally, she revealed that this incident occurred in the sunroom and not in the resident's bedroom. Record review of an MDS assessment dated [DATE] for Resident ID #4 revealed a BIMS score of 15 out of 15, indicating s/he had no cognitive impairments. During a surveyor interview with Resident ID #4 on 10/8/2024 at approximately 9:35 AM s/he revealed, while s/he was in the sunroom on 10/6/2024, s/he witnessed Resident ID #1 touching Resident ID #2 s/he placed his/her hands on Resident ID #2's thigh. Resident ID #4 further revealed that Resident ID #1 began moving his/her hands towards Resident ID #2's upper thigh at which time s/he interceded and told Resident ID #1 to stop what s/he was doing. Resident ID #4 then indicated that Resident ID #1 left the area that. Resident ID #4 indicated that s/he then reported the incident to the facility's staff. Record review of a police report dated 10/8/2024 reveals that the police were dispatched to the facility on [DATE] for a report that Resident ID #1 was witnessed by Resident ID #4 touching Resident ID #2 on his/her legs and genitals on the outside of his/her underwear. Additional review revealed that Resident ID #1 was arrested for second degree sexual assault.

Jul 2024 6 deficiencies

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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

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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 develop and implement a comprehensive person-centered care plan for 1 of 5 residents reviewed relative to smoking, Resident ID #186. Findings are as follows: According to the facility policy titled Smoking Policy reviewed and revised in 2/2024, states in part, .PROCEDURE . 3. Residents who are identified as smokers are to have a Comprehensive Care Plan for smoking developed by the Interdisciplinary Care Team . Record review revealed the resident was admitted to the facility in May of 2024 with a diagnosis including, but not limited to, nicotine dependence, cigarettes. Record review revealed a smoking assessment dated [DATE] was completed upon admission to the facility which indicated the resident is a smoker. Record review revealed a smoking assessment dated [DATE] was completed upon re-admission to the facility which indicated the resident is a smoker. Further record review failed to reveal evidence that a comprehensive care plan was developed and implemented for smoking. During a surveyor interview on 7/26/2024 at 8:35 AM with the Director of Nursing Services, she acknowledged that the resident was a smoker. Additionally, she acknowledged that a comprehensive care plan was not developed relative to smoking.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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

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Based on record review and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of practice relative to following physician's orders for 1 of 3 residents reviewed for obtaining laboratory results, Resident ID #162, and 1 of 1 resident reviewed for obtaining a psychiatric consult and daily weights, Resident ID #241. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, .The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients . 1. Record review revealed Resident ID #162 was admitted to the facility in July of 2022 with a diagnosis including, but not limited to, seizure disorder. Record review revealed an order dated 10/26/2023 for Valproic Acid (medication to treat seizures) 250 milligrams per 5 milliliters (mL), give 10 mL by mouth three times a day for seizures. Record review revealed an order with a start date of 6/12/2024, to obtain bloodwork; a CMP (comprehensive metabolic panel-tests the body's chemical balance and metabolism), and Valproic Acid level (measures the amount of valproic acid level) every 6 months. Record review of the June 2024 Laboratory Administration Record revealed the order to obtain a CMP and a Valproic Acid level every 6 months was transcribed with a start date of 6/12/2024. Further record review revealed the order was not signed off as completed on 6/12/2024. Record review failed to reveal evidence of the laboratory results for the CMP or Valproic Acid levels. During a surveyor interview with the Director of Nursing Services (DNS) on 7/26/2024 at 1:41 PM, she was unable to provide evidence of the laboratory results for the CMP and the Valproic Acid levels. Additionally, she would expect the laboratory work would be obtained, as ordered. 2. Record review revealed Resident ID #241 was admitted to the facility in July of 2024 with diagnoses including, but not limited to, cirrhosis of the liver (a condition in which the liver is scarred and permanently damaged), ascites (fluid accumulation in the abdomen), and a history of depression. a. Record review revealed a physician's order dated 7/12/2024 with a start date of 7/13/2024 to obtain daily weights. Record review of the documented weights revealed the resident's weights were not obtained daily as ordered on 7/18/2024 and 7/19/2024. b. Record review revealed a physician's order dated 7/12/2024 to obtain a psychiatric consult for a history of psychosis (a mental disorder that affects a person's ability to recognize reality and relate to others). Further review revealed a subsequent physician's order dated 7/22/2024 to obtain a psychiatric consult for a history of depression. Record review failed to reveal evidence that the resident was seen and evaluated by psychiatric services. During a surveyor interview with the resident's physician, Staff A, on 7/26/2024 at 12:30 PM, she indicated that she wanted the resident to be evaluated by psychiatric services before implementing any medications. During a surveyor interview with the DNS on 7/26/2024 at 8:35 AM, she was unable to provide evidence that the resident was seen and evaluated by psychiatric services. Additionally, she acknowledged the resident was not weighed daily on the above-mentioned dates, as ordered.

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary services to a resident who is unable to carry out activities of daily living relative to scheduled showers for 1 of 1 resident reviewed who had concerns regarding shower provision, Resident ID #111. Findings are as follows: Record review revealed the resident was admitted to the facility in June of 2023 with diagnoses including, but not limited to, severe morbid obesity and generalized muscle weakness. Record review of a Quarterly Minimum Data Set assessment dated [DATE] revealed the resident is dependent with bathing and showering, and s/he requires staff assistance to complete these tasks. Record review of a care plan dated 1/8/2024 revealed the resident requires assistance with self-care and mobility and is dependent with showers and bathing. Record review of a physician's order dated 7/4/2024 revealed an order for biweekly showers scheduled on Mondays and Thursdays during the day shift. During a surveyor observation of the resident on 7/24/2024 at 8:56 AM and on 7/25/2024 at 9:26 AM, s/he was observed in bed, upon entering the room, a strong odor of urine was noted. During a surveyor interview on 7/24/2024 at 8:58 AM and on 7/25/2024 at 9:28 AM, with the resident s/he indicated that s/he had not had a shower since s/he moved onto the unit in May of 2024 and would like to have a shower. The resident indicated that s/he was told by the staff that s/he could not get a shower because the shower chair was broken. During a surveyor interview on 7/25/2024 at approximately 9:36 AM with Nursing Assistant (NA), Staff B, she indicated that she is the resident's primary NA. She indicated has not given the resident a shower since she started providing care to the resident when s/he moved onto the unit in May of 2024. Staff B further indicated that she was the resident's NA on 7/22/2024 and on 7/25/2024 and had not given the resident a shower on both dates, as ordered. Additionally, Staff B acknowledged that the shower chair is not broken and could not provide evidence the resident has received showers, as ordered. During a surveyor interview on 7/25/2024 at 9:47 AM, with the unit manager, Licensed Practical Nurse, Staff H, he could not provide evidence that the resident received showers, as ordered. During a surveyor interview on 7/25/2024 at 1:45 PM, with the Director of Nursing Services, she was unable to provide evidence the resident received showers, as ordered.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide 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 provide respiratory care consistent with professional standards of practice for 1 of 2 residents reviewed for respiratory care, Resident ID #159. Findings are as follows: According to Lippincott Manual of Nursing Practice 10th Edition, 2014, page 240, states in part, .Administering Oxygen by Nasal Cannula [a device that is used to deliver oxygen through a tube to your nose] .1. Record flow rate used and immediate patient response . Record review of a facility policy titled, Oxygen Administration states in part, .Documentation .2. Document the date, time, amount, and method of oxygen administration. 3. Document the resident's condition before and after the initiation of therapy. 4. Ensure that there is evidence of oxygen administration for the duration of the therapy . Record review revealed the resident was admitted to the facility in September of 2022 and readmitted in July of 2024 with diagnoses including, but not limited to, lung cancer, shortness of breath, and pneumonia. Record review of a physician's order dated 6/17/2024 states in part, Oxygen 2-4L [liters] via Nasal Cannula Titrate [to evaluate your oxygen needs at rest or during exercise] as able, keep POX [pulse oximetry, a method of measuring the saturation of oxygen in a person's blood] > [greater than] 88 r/a [room air] every 1 hour as needed .Document liters and POX . Record review of the vital report on the following dates and times revealed the resident was administered oxygen but failed to reveal evidence of the amount/liters of oxygen administered to the resident, as per the facility's policy: - 7/25/2024 at 11:35 AM - 7/24/2024 at 3:49 PM - 7/24/2024 at 1:08 PM - 7/23/2024 at 8:06 AM - 7/19/2024 at 9:49 AM - 7/14/2024 at 10:13 PM During a surveyor observation on the following dates and times, the resident was observed on 2 liters of oxygen: - 7/25/2024 at 10:56 AM - 7/25/2024 at 12:04 PM - 7/26/2024 at 9:15 AM Further record review of the Treatment Administration Record for July 2024 failed to document that the resident received oxygen on 7/25/2024 and 7/26/2024, per the facility's policy. During a surveyor interview on 7/26/2024 at 11:21 AM, with the resident's physician, Staff A, she indicated that she would expect the staff to document the date, time, and amount of oxygen that is being administered to a resident each time when oxygen is administered.

CONCERN (D) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with profess...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and practices for 1 of 1 resident reviewed for showers and 1 of 4 residents reviewed for non-pressure wound treatments, Resident ID #111, and 1 of 1 resident reviewed for psychiatric evaluations, Resident ID #241. Findings are as follows: 1. Record review revealed Resident ID #111 was admitted to the facility in June of 2023 with diagnoses including, but not limited to morbid obesity and generalized muscle weakness. Record review revealed the following physician's orders: - Weekly shower schedule: Monday 7-3 and Thursday 7-3 every day shift - Apply calazime (skin protectant cream) to left posterior thigh twice daily every day and evening shift, document refusals of treatment Additional record review revealed a Nursing Assistant assignment log which indicated the resident is schedule for showers on Tuesdays and Fridays on the first shift. Record review of the July 2024 Treatment Administration Record revealed that Registered Nurse, Staff G, signed off that the resident had received a shower and that his/her wound treatment to the left posterior thigh had been completed on 7/25/2024. During a surveyor interview on 7/25/2024 at 9:36 AM, with Nursing Assistant (NA), Staff B, she revealed that she is the resident's primary NA and was the assigned NA to provide care including shower to the resident on 7/25/2024. She further acknowledged that she had not given a shower to the resident on 7/25/2024, as documented. During a surveyor interview on 7/25/2024 at 10:14 AM, with Staff G, he acknowledged he had inaccurately documented that Resident ID #111 had received a shower and his/her wound treatment had been completed on 7/25/2024. During a surveyor interview on 7/25/2024 at 1:45 PM, with the Director of Nursing Services (DNS), she could not provide evidence that the resident's record was accurately documented to reflect the care and services s/he received on 7/25/2024. 2. Record review revealed Resident ID #241 was admitted to the facility in July of 2024 with diagnoses including, but not limited to, cirrhosis of the liver (a condition in which the liver is scarred and permanently damaged), ascites (fluid accumulation in the abdomen), and a history of depression. Record review of the physician's orders revealed an order dated 7/12/2024 which states in part, Psych consult for h/o [history of] psychosis . Record review of a Behavioral Health Visit Request/Follow Up form indicated the consulting psychiatric provider signed off that she had completed the psychiatric consult for the resident on 7/13/2024. Additional record review failed to reveal evidence that the resident was seen by psychiatric services on 7/13/2024. During a surveyor interview on 7/26/2024 at 8:35 AM, with the DNS, she was unable to provide evidence that the resident was seen and evaluated by the consulting psychiatric provider as ordered. After it was brought to the facility's attention by the surveyor, the Assistant Director of Nursing Services provided an email correspondence with the consulting psychiatric provider, dated 7/26/2024 at 11:37 AM, revealing that the provider did not complete a psychiatric evaluation for the resident.

CONCERN (E)

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

Deficiency F0760 (Tag F0760)

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 residents are free of any significant medication errors for 4 of 9 residents reviewed for med...

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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 4 of 9 residents reviewed for medication administration, Resident ID #s 111, 136, 162, and 186. Findings are as follows: 1. Record review revealed Resident ID #111 was admitted to the facility in June of 2023 with diagnoses including, but not limited to, hypertension (high blood pressure) and acute kidney failure. Record review revealed a physician's order dated 3/12/2024 for furosemide (Lasix - diuretic) 20 milligrams (mg), give 1 tablet at 7:00 AM for heart failure. Review of a progress note dated 7/22/2024 at 4:04 PM revealed the Nurse Practitioner (NP), Staff C, ordered the Lasix to be held for 3 days based on the resident's laboratory results. Review of the July 2024 Medication Administration Record (MAR) revealed that his/her Lasix was not held as ordered, and the resident received Lasix on 7/23, 7/24, and 7/25/2024 in error. During a surveyor interview on 7/25/2024 at 9:31 AM, with Staff C, she acknowledged that the resident's Lasix was not held as ordered on the above-mentioned dates and would have expected the medication to be held. 2. Record review revealed Resident ID #136 was admitted to the facility in November of 2021 with diagnoses including, but not limited to, gastric ulcer (open sore in your stomach lining) and diabetes mellitus. 2a. Review of a document titled, ORDER LOG FOR PCC [Point Click Care] dated 7/8/2024 revealed a physician's order for Resident ID #136 to start metronidazole (an antibiotic) 250 mg, give four times daily for 14 days. Review of the July 2024 MAR revealed that the order was incorrectly transcribed as metronidazole 500 mg twice daily and not 250 mg four times daily, as ordered. The resident received the incorrect dose and frequency of the medication for 14 days from 7/9/2024 through 7/22/2024. During a surveyor interview on 7/26/2024 at 12:33 PM with the resident's physician, Staff A, she revealed that the resident should have received the metronidazole as prescribed. 2b. Review of a document titled, ORDER LOG FOR PCC dated 7/8/2024 revealed a physician's order for metformin (medication to help lower blood sugar) 500 mg, twice daily. Record review failed to reveal evidence that the above-mentioned order for metformin was transcribed, resulting in the resident failing to receive 34 doses of the medication. During a surveyor interview on 7/25/2024 at 9:36 AM, with the Unit Manager, Staff D, after the medication errors were brought to Staff D's attention, she acknowledged that she failed to transcribe the order for metformin. Additionally, she acknowledged that she transcribed the order for metronidazole as 500 mg twice daily in error, and not the ordered 250 mg four times daily. 3. Record review revealed Resident ID #162 was admitted to the facility in July of 2022 with a diagnosis including, but not limited to, seizures. Record review revealed a physician's order dated 10/26/2023 for Valproic Acid 250 mg per 5 milliliters, give 500 mg at 6:00 AM, 2:00 PM, and 9:00 PM for seizures. Review of the July 2024 MAR failed to reveal evidence that the resident received his/her Valproic Acid on 7/16 and 7/21 at 6:00 AM, or that the provider was notified that the resident did not receive his/her medication, as ordered. During a surveyor interview on 7/26/2024 at 1:18 PM with Licensed Practical Nurse, Staff E, she acknowledged that the medication was not administered to the resident on the above-mentioned dates and times. During a surveyor interview with NP, Staff C, on 7/26/2024 at 1:31 PM, she revealed that she was unaware that the resident did not receive the Valproic Acid on the above-mentioned dates and times, as ordered. Additionally, she would expect medication orders to be followed and to be notified of any missed doses. 4. Record review revealed Resident ID #186 was admitted to the facility in May of 2024 with diagnoses including, but not limited to, abnormal findings of blood chemistry and heart failure (a condition when the heart pumps inadequately). Review of a nursing progress note dated 7/18/2024 at 12:41 PM, revealed a new order to hold Lasix 20 mg for 3 days, and start 40mg of Lasix for 3 days. Review of a provider progress note dated 7/18/2024 at 3:17 PM, authored by NP, Staff C, states in part, .HF: [heart failure] Lasix 40mg for 3 days, ctm [continue to monitor] for fluid overload . Record review revealed the following physician orders: -7/12/2024 Lasix 20 mg give 1 tablet once daily for fluid retention, hold from 7/18/2024 to 7/21/2024. -7/19/2024 Lasix 40 mg give 1 tablet in the morning for 3 days, start 7/19/2024. Review of the July 2024 MAR failed to reveal evidence that the Lasix 20mg was held on 7/21, as ordered. Additionally, the Lasix 20 mg was signed off as administered on 7/21 by Certified Medication Technician, Staff F. Further review of the MAR revealed that the Lasix 40mg order was also signed off as administered by Staff F, indicating the resident received a total dose of Lasix 60 mg, instead of the ordered dose of Lasix 40mg. During a surveyor interview on 7/25/2024 at 2:02 PM with Staff F, she acknowledged that she administered Lasix 60 mg to the resident on 7/21/2024. During a surveyor interview on 7/26/2024 at 8:45 AM with the DNS, she was unable provide evidence the resident's Lasix order followed.

Nov 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0604 (Tag F0604)

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 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 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 11/6/2023 states in part, that at approximately 11:05 AM a nursing assistant reported that Resident ID #1 was found with his/her lower extremities restrained to the bed with his/her bed sheets on 11/5/2023. Record review of the facility's policy and procedure for restraint use states in part, it is the policy of this facility that all residents have the right to be free of physical restraints imposed for the purpose of discipline or employee convenience. Physical restraints can only be used in circumstances in which the application is decided to be in the best interest of the resident based on the professional opinions of the appropriate members of the interdisciplinary team . Record review revealed that the resident was readmitted to the facility in October of 2023 with diagnoses including, but not limited to, Alzheimer's disease, dementia with behavioral disturbance, and major depressive disorder. Record review of the quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 8 out of 15, indicating the resident has moderately impaired cognition. Record review of the resident's care plan dated 5/1/2023 reveals s/he has an activity of daily living self-care performance deficit relative to impaired balance and limited mobility. Interventions include, but are not limited to, chair to bed and bed to chair transfer. Record review of the progress notes revealed the following entries: -10/30/2023, approximately 4:12 AM, resident restless attempting to get up out of bed at the beginning of the 11:00 PM shift. -11/2/2023, approximately 10:07 PM, resident pulled out foley. -11/4/2023, approximately 9:24 PM, the resident was trying to transfer him/herself from the bed to the chair and s/he fell on his/her buttock. During a surveyor interview on 11/7/2023 at 11:33 AM with Nursing Assistant (NA), Staff A, she revealed that NA, Staff B, came to her for help on 11/5/2023 because she couldn't turn the resident in the bed. She further revealed when she went to the resident's room she witnessed the resident's sheets tied to the bedframe on each side of the bed and the sheet was wrapped around the resident's feet. She further indicated Staff B saw the sheets knotted to the foot raiser and wrapped around the resident's feet. During a surveyor observation on 11/7/2023 at 12:30 PM, Staff A demonstrated how the resident's bed looked on 11/5/2023 when she went in to go help with his/her care. She raised the foot of the bed, took a sheet and folded it to have a small width which she then knotted it around the bedframe twice. She indicated the foot of the bed would need to be raised to untie the knotted sheets. Additionally, she revealed a second sheet was wrapped around the resident's feet and tied to the bedframe. During a surveyor interview on 11/8/2023 at 9:44 AM with Staff B in the presence of NA and interpreter Staff C, she revealed that when Staff A lifted the resident's sheet she saw a bedsheet that was tied to the bedframe. She further revealed that his/her feet were wrapped in the sheet. During a subsequent interview with Staff B in the presence of the Regional Director on 11/8/2023 at approximately 3:30 PM, she only revealed she saw the resident's legs wrapped up in the sheets, not tied. During a follow up interview on 11/10/2023 at approximately 10:00 AM with Staff C, she reiterated that Staff B stated to this surveyor that she saw the resident's bed sheets tied to the bed frame. During a surveyor interview on 11/14/2023 at approximately 10:20 AM with the Director of Nursing in the presence of the Administrator and the Assistant Director of Nursing, she could not provide evidence that the resident was free from a physical restraint.

Aug 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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, it has been determined that the facility failed to ensure that the residents are free from significant medication errors for 3 of 4 residents reviewed who were receiving pain medication, Resident ID #s 1, 3, and 4. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 7/31/2023 alleges that Resident ID #1 had three errors concerning his/her pain medication in the last six days. 1. Record review for Resident ID #1 revealed s/he was re-admitted to the facility in May of 2023 with diagnoses including, but not limited to, osteoarthritis, migraine, and myalgia (pain in a group of muscles). Record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed s/he had a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. During a surveyor interview with Resident ID #1 on 7/31/2023 at approximately 2:00 PM, s/he revealed that there was one occasion where s/he was given one pill, instead of two pills for his/her pain. Record review for Resident ID #1 revealed the following physician orders: - Oxycontin oral tablet ER (extended release) 10 mg (milligrams) by mouth one time a day for pain with a start date of 6/23/2023 and a discontinue date of 7/12/2023. - Oxycodone oral tablet (immediate release) 10 mg by mouth every 8 hours as needed for pain with a start date of 7/19/2023. a. Record review of the 2nd floor North Unit narcotic book revealed that the Oxycontin 10 mg tablet was signed off and removed from the medication cart on 7/25/2023 at 8:00 AM. Record review of the July 2023 Medication Administration Record (MAR) revealed that the Oxycodone 10 mg tablet was signed off as administered to the resident. During a surveyor interview with the Licensed Practical Nurse (LPN), Staff A, on 7/31/2023 at 1:39 PM, he revealed that he was training LPN, Staff E, on 7/26/2023. He indicated that Staff E mistakenly administered the Oxycontin 10 mg instead of the Oxycodone 10 mg to the resident on 7/26/2023. Staff A also indicated that this error occurred on 7/26/2023 and not 7/25/2023 as Staff E had documented in the narcotic book. Staff A also acknowledged that Staff E signed off on the MAR that he administered Oxycodone on 7/26/2023 when he actually administered Oxycontin. During a surveyor interview with the Director of Nursing Services in the presence of the Interim Administrator on 7/31/2023 at approximately 2:40 PM, she acknowledged that Resident ID #1 mistakenly received Oxycontin 10 mg instead of the Oxycodone 10 mg as ordered on 7/26/2023. b. Record review of the 2nd floor North Unit narcotic book for Resident ID #1 revealed that on 7/24/2023, two tablets of Oxycodone 5 mg for a total of 10 mg were signed off and removed from the medication cart at 5:40 PM, and one tablet of Oxycodone 5 mg was signed off and removed from the medication cart at 8:00 PM. Both 5:40 PM and 8:00 PM doses were signed off by Staff B. Record review of Resident ID #1's July 2023 MAR failed to reveal evidence that the one tablet of Oxycodone 5 mg signed off and removed from the medication cart at 8:00 PM was administered to the resident on 7/24/2023. Additionally, the facility could not provide evidence on where the Oxycodone 5 mg tablet went as it was not signed off on the MAR as being administered to the resident. During a surveyor interview on 7/31/2023 at 4:40 PM with LPN, Staff B, who was assigned to Resident ID #1 on 7/24/2023, she acknowledged that she administered two tablets of Oxycodone 5 mg at 5:40 PM but denied administering the one tablet of Oxycodone 5 mg to the resident at 8:00 PM. Additionally, she was unable to explain why an extra dose of Oxycodone 5 mg was signed off in the narcotic book as removed from the medication cart, but was not signed off as administered on Resident ID #1's MAR. During an additional interview with Staff B on 8/1/2023 at 11:22 AM, she revealed that she thinks someone is forging her signature as it doesn't make sense to give the same medication to the resident at 6:00 PM and again at 8:00 PM. Additionally, she acknowledged that she was the only nurse that had the keys to the 2nd floor North Unit nursing medication cart on 7/24/2023. c. Further record review of the 2nd floor North Unit narcotic book for Resident ID #1 revealed that on 7/26/2023 at 6:20 PM, LPN, Staff C, removed one tablet of Oxycodone 5 mg from the medication cart instead of two tablets of Oxycodone. Record review of the July 2023 MAR revealed that the resident received 10 mg of Oxycodone on 7/26/2023, despite Staff C signing off in the narcotic book that only one tablet of Oxycodone 5 mg was removed from the medication cart. During a surveyor interview with Staff C on 7/31/2023 at 4:30 PM, she was unable to recall what dose of Oxydocone she gave to Resident ID #1 on 7/26/2023. Additionally, she could not why explain she only signed out one tablet when the order was for two. 2. Record review for Resident ID #3 revealed s/he was re-admitted to the facility in June of 2023 with diagnoses including, but not limited to, osteoarthritis, right hip and knee replacement, and wedge compression fracture. Record review for Resident ID #3 revealed the following physician orders: - Oxycodone tablet 7.5 mg by mouth three times a day for pain with a start date of 5/17/2023 and a discontinue date of 7/12/2023. - Oxycodone tablet 10 mg by mouth three times a day for pain management with a start date of 7/12/2023 and a discontinue date of 7/27/2023. Record review of the 2nd floor North Unit narcotic book for Resident ID #3 revealed that the Oxycodone 10 mg tablet was signed off as removed from the medication cart on 7/21/2023 at 7:53 PM. Record review of the July 2023 MAR revealed that the resident received the Oxycodone 10 mg on 7/21/2023 at 8:00 PM. Further record review of the narcotic book revealed that the Oxycodone 7.5 mg tablet was also signed off and removed from the medication cart by Staff B on 7/21/2023 at 7:53 PM, although record review of the July 2023 MAR failed to reveal evidence that it was administered to the resident. Additionally, the facility could not provide evidence on where the Oxycodone 7.5 mg tablet went or if it was administered to the resident. During a surveyor interview with Staff B on 7/31/2023 at 4:40 PM, she denied administering the discontinued Oxycodone 7.5 mg to the resident on 7/21/2023. She could not explain why she signed out the Oxycodone 7.5 MG tablet on 7/21/2023 when it was a discontinued order. 3. Record review for Resident ID #4 revealed s/he was re-admitted to the facility in March of 2023 with diagnoses including, but not limited to, unspecified fracture of lumbar vertebra and spinal stenosis (a condition where spinal column narrows and compresses the spinal cord). Record review for Resident ID #4 revealed a physician order with a start date of 7/28/2023 for Hydromorphone 2 mg, give 0.5 tablet (1 mg) by mouth every 6 hours as needed for moderate pain. Record review of the 2nd floor North Unit narcotic book revealed that the Hydromorphone 0.5 tablet (1mg) was signed off as removed by the LPN, Staff D, on 7/30/2023 at 8:00 PM. Record review of the July 2023 MAR for Resident ID #4 failed to reveal evidence that the Hydromorphone was administered to the resident on 7/30/2023 at 8:00 PM. During a surveyor interview with Staff D on 8/1/2023 at 9:05 AM, she revealed that she did administer the medication. Additionally, she was unable to provide evidence that the resident received it. During a surveyor interview with the Director of Nursing Services in the presence of the Interim Administrator on 7/31/2023 at approximately 2:40 PM, she was unable to provide evidence that the Hydromorphone was administered to Resident ID #4 on 7/30/2023 at 8:00 PM after it was signed off in the narcotic book and removed from the medication cart.

Jun 2023 10 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 F0692 (Tag F0692)

A resident was harmed · This affected 1 resident

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

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Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight for 2 of 14 residents reviewed for nutrition, Resident ID#s 115 and 93. Findings are as follows: Record review of the State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities, revised on 2/3/2023, reveals a weight loss of 5% in 1 month, 7.5% in 3 months, and 10% in 6 months is significant weight loss. Additionally, greater than 5% in 1 month, greater than 7.5% in 3 months, and greater than 10% in 6 months is severe weight loss. Review of the facility's policy and procedure, undated and untitled, was provided by the facility which states in part, .If the weight shows a discrepancy of (+) or (-) 5 pounds, the nurse is to be notified who will then be required to supervise the reweight . MONTHLY WEIGHTS: 1. Monthly weights will be obtained on first shift . 2. The charge nurse will ensure that the weight provided by the aid is accurate. 3. If the resident has a 5 pound variance, the nurse and the aid will re-check the weight within 24 hours. If the weight continues to show a variance, the nurse will contact the MD and Dietician at which time appropriate orders/recommendations will be made . 4. Weights will be recorded by the charge nurse (7-3), in the computer and signed off. 1. Record review for Resident ID #115 revealed s/he was admitted to the facility in March of 2023 with diagnoses including, but not limited to, adult failure to thrive and severe-protein calorie malnutrition. Record review of an admission Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 11 out of 15, indicating that the resident has mild cognitive impairment. Record review of the care plan initiated on 3/17/2023 with a focus for nutritional problem with interventions including, but not limited to, offering dietary supplements and snacks as the resident will tolerate. Further record review of the physician's orders revealed an order dated 4/26/2023 for ice cream with every meal. Record review of the resident's diet slip failed to reveal documentation indicating that the resident is to receive ice cream with every meal. Surveyor observations revealed ice cream was not provided to the resident during his/her meals on the following dates and meals: -6/5/2023 during the lunch meal -6/6/2023 during the lunch meal -6/7/2023 during the lunch meal During a surveyor interview on 6/7/2023 at 12:53 PM with Nursing Assistant, Staff C, she revealed she has been taking care of the resident since s/he was admitted . Staff C revealed the resident likes ice cream and if s/he wants ice cream, s/he will call the kitchen to have ice cream sent up for the resident. Record review revealed the resident was discharged to an acute care facility on 4/6/2023 and returned to the facility on 4/8/2023. Record review revealed the following weights on the following dates and times: -6/2/2023 125.0 Lbs. -6/1/2023 125.0 Lbs. -5/30/2023 123.2 Lbs. -5/24/2023 124.2 Lbs. -5/22/2023 122.0 Lbs. -5/18/2023 121.0 Lbs. -5/12/2023 134.2 Lbs. -5/11/2023 133.6 Lbs. -5/10/2023 135.2 Lbs. -5/9/2023 133.2 Lbs. -5/8/2023 133.4 Lbs. -5/7/2023 133.4 Lbs. -5/5/2023 133.8 Lbs. -5/4/2023 138.2 Lbs. -4/30/2023 128.8 Lbs. -4/29/2023 128.2 Lbs. -4/28/2023 130.6 Lbs. -4/27/2023 135.8 Lbs. -4/26/2023 135.0 Lbs. -4/26/2023 135.0 Lbs. -4/25/2023 138.2 Lbs. -4/24/2023 138.0 Lbs. -4/23/2023 141.0 Lbs. -4/20/2023 151.2 Lbs. -4/20/2023 154.5 Lbs. -4/19/2023 155.0 Lbs. -4/18/2023 154.6 Lbs. -4/17/2023 157.2 Lbs. -4/16/2023 159.0 Lbs. -4/13/2023 159.2 Lbs. Record review of the weights documented revealed the resident experienced a weight loss of 24.2 Lbs. (15.2%) in 13 days, from 4/13/2023 to 4/26/2023. Additionally, the facility obtained an order for ice cream to be given to the resident with all meals. Record review failed to reveal evidence that the ice cream was provided with all meals, as ordered by the physician on 4/26/2023. Further record review revealed the resident continued to lose an additional 10 Lbs. from 4/26/2023 to 6/2/2023, indicating a severe weight loss of 34.2 Lbs. (21.5%) since 4/13/2023. During a surveyor interview with the Registered Dietitian (RD) on 6/8/2023 at 11:58 AM, she revealed that the ice cream was ordered with the goal to help prevent further weight loss. Additionally, the RD could not explain why the ice cream order was not added to the resident's diet slip. During a surveyor interview with the resident on 6/7/2023 at 1:04 PM, the resident revealed s/he likes ice cream. The resident further revealed s/he could not recall the last time s/he received ice cream with his/her meal. During a surveyor interview on 6/7/2023 at 1:08 PM with Licensed Practical Nurse, Staff L, she revealed staff will call the kitchen if the resident requests ice cream as ice cream is not supplied on the unit. She further revealed she wrote the order for the ice cream with all meals. When asked how they communicate diet orders with the kitchen staff, she revealed they write the diet order on a diet slip and send that to the kitchen. Additionally, she acknowledged that the resident's diet ticket did not include ice cream with meals. During a surveyor interview with the Director of Nursing Services (DNS) on 6/7/2023 at 2:17 PM and again at 5:20 PM, she revealed that the ice cream is provided by the kitchen. Additionally, she could not explain why the ordered ice cream was not provided to the resident. During a surveyor interview on 6/8/2023 at 11:08 AM with the Food Service Director, she revealed she was unaware of the order for ice cream with meals and that no one sent the diet slip down to the kitchen for ice cream. 2. Record review for Resident ID #93 revealed s/he was admitted to the facility in September of 2018 with diagnoses including, but not limited to, severe protein-calorie malnutrition and Alzheimer's disease. Record review of the resident's weights revealed the following: -4/10/2023 107.3 Lbs. -5/16/2023 100.8 Lbs. -6/1/2023 99.8 Lbs. Record review revealed the resident had a weight loss of 7.5 Lbs. (6.99 %) from 4/10/2023 to 6/1/2023. Additionally, the record failed to reveal evidence that the resident was reweighed within 24 hours after s/he experienced a weight loss of > 5 pounds. During a surveyor interview on 6/8/2023 at 3:30 PM with the resident's provider, she revealed she was aware of the resident's weight loss and further revealed that she did not implement a new intervention. Additionally she acknowledged she did not contact the resident's family to discuss possible interventions that could have been implemented to address the resident's weight loss. During a surveyor interview on 6/8/2023 at 3:43 PM with the RD, she revealed she was unaware that the resident had a weight loss as indicated above. Additionally, she revealed that if she would have known about the weight loss, she would have reweighed the resident to verify the weight loss. Further, if the weight loss was accurate as documented above, she would have recommended weekly weights to be obtained, a speech evaluation and she would have the resident reviewed during the facility Risk Team Meetings. During a surveyor interview on 6/8/2023 at 4:02 PM with the Licensed Practical Nurse/Unit Manager (UM), Staff Q, she revealed the UM is supposed to review all the weights. Staff Q further revealed that both she and the RD missed the weight loss. During a surveyor interview with the DNS on 6/12/2023 at approximately 4:30 PM, she acknowledged the resident had a weight loss as indicated above. Additionally, she could not explain why the resident was not reweighed, per their policy.

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 F0697 (Tag F0697)

A resident was harmed · This affected 1 resident

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, it has been determined that the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 resident reviewed for pain management, Resident ID #159. Findings are as follows: Record review of the facility policy titled Pain Assessment states in part, .III. Intervention will be required for: 1. Any pain that is not managed. 2. If the resident's comfort goal has not been met . IV. Residents who experience pain shall have: . 2. All complaints of unrelieved pain reported to the physician for proper review of the pain relief regime. 3. Pain consults requested as per physician recommendation when necessary to eradicate previously unrelieved pain . Record review for the resident revealed s/he was admitted to the facility in November of 2022 with a diagnosis including, but not limited to, complex regional pain syndrome (CRPS) of bilateral lower limb. Review of the Minimum Date Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. During a surveyor interview with the resident on 6/5/2023 at 4:29 PM, s/he reported that his/her pain was not being managed properly. Record review of the June 2023 Medication Administration Record revealed the resident reported pain at a level of 10 out of 10 for 7 out of 16 opportunities from 6/1/2023 to 6/6/2023. Record review of the resident's neurology appointment report dated 2/8/2023 states in part, .Severe right foot and leg pain with causalgia [severe burning pain in a limb caused by injury to a peripheral nerve] that may be caused by CRPS since other organic causes have been excluded. Patient has severe pain despite taking three neuropathic pain medications, notably nortriptyline, gabapentin, and duloxetine [medications to treat pain]. Patient felt better on oxycodone, but it was discontinued recently. [S/he] is using Morphine currently, but [s/he] says that medication is also due to be stopped. [His/her] remaining treatment options for CRPS are a ganglion block [injection of anesthetic medication into a collection of nerves] to the right leg or treatment with a long-acting opiate such as suboxone or Butrans . Record review of the progress notes revealed a note dated 3/2/2023 which states in part, .admission denied at Codac [an outpatient provider for opioid treatment in Rhode Island] due to patient denied opiate use history. New guideline from DOH [Department of Health]. No restriction in prescribing buprenorphine [Butrans]. Facility MD [Doctor of Medicine] can prescribe buprenorphine . Record review of the resident's neurology appointment report dated 5/9/2023 states in part, .Severe right foot and leg pain with causalgia attributed to CRPS which remains very severe on gabapentin 1100 mg [milligrams] tid [three times a day] and duloxetine 120 mg qd [daily] .[His/Her] treatment options are limited because [s/he] has already tried and failed nortriptyline and pregabalin [medication for nerve pain] and is using high dosages of gabapentin and duloxetine. Patient has also failed nerve blocks and a neurostimulator. [His/Her] remaining pain management options are a ganglion block or treatment with long-acting opiate such as Butrans, suboxone, or methadone [medications for treatment of pain] . Further record review of the above recommendations revealed that the resident's physician was notified of the above-mentioned recommendations from the neurologist appointment on 2/8/2023 and he was also notified of the subsequent recommendations from the neurologist on 5/9/2023, Additionally, the 5/9/2023 document from the neurologist was signed by the physician on 5/17/2023. During a surveyor telephone interview with the resident's physician on 6/7/2023 at 5:35 PM, he acknowledged that he reviewed the neurology recommendations on 5/9/2023 and revealed that he is not licensed to prescribe Butrans, suboxone, or methadone. Additionally, he was unable to provide evidence that an alternative pain management was initiated following the resident's neurology appointment on 5/9/2023. During a surveyor interview on 6/8/2023 at approximately 3:30 PM with the Director of Nursing Services and the Administrator, they were unable to provide evidence that the resident's pain was managed.

CONCERN (D) 📢 Someone Reported This

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

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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

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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to prevent new pressure ulcers from developing for 2 of 10 residents reviewed, Resident ID #s 3 and 173. Finding are as follows: 1. Review of the record for Resident ID #3 revealed s/he was admitted to the facility in January of 2023 with diagnoses including, but not limited to pressure ulcer of sacral region (the portion of your spine between your lower back and tailbone) stage 4 (pressure ulcer that is a deep wound reaching the muscles, ligaments, or bones) and type two diabetes mellitus. Record review revealed a physician's order dated 3/6/2023 for bilateral cushioned booties to be worn while in bed. Review of his/her care plan revised on 4/29/2023, revealed that s/he has a pressure ulcer to the coccyx (tailbone) with an intervention for bilateral cushioned booties to be worn when in bed. Surveyor observations revealed the resident lying in bed without the ordered cushioned booties on the following dates and times: -6/7/2023 at 9:29 AM, 1:55 PM, and 3:11 PM -6/8/2023 at approximately 8:30 AM and 11:35 AM During an observation and simultaneous interview on 6/8/2023 at 11:35 AM with Licensed Practical Nurse/Unit Manager, Staff B, she acknowledged that the resident was without the cushioned booties while lying in bed. Additionally, she would expect that the nursing assistants apply the booties and that the unit nurse would ensure that the resident is wearing the booties while in bed. 2. Record review revealed Resident ID #173 was admitted to the facility in September of 2022 with a primary diagnosis of cerebral palsy (a group of movement disorders that appear in early childhood-signs and symptoms include poor coordination, stiff muscles, weak muscles, and tremors). Further record review revealed the resident has a history of a stage 3 pressure ulcer (full thickness skin loss) of the sacral region. Review of the physician's orders dated 10/26/2022 revealed an air loss mattress (design to distribute the patient's body weight over a broad surface area) to be set at 145 lbs. (pounds) to prevent skin breakdown. Review of the care plan, revised on 10/7/2022, revealed that the resident has potential for impairment to his/her skin relative to a history of pressure injury to the coccyx area and immobility with an intervention for a pressure relieving/reducing mattress to protect the skin while in bed. Surveyor observations revealed the resident lying in bed and the red light on the air mattress machine was blinking, indicating low pressure. Additionally, surveyor observations failed to reveal evidence that the air loss mattress was set at 145 lbs., per the physician's order, on the following dates and times: -6/5/2023 during initial tour approximately 9:00 AM -6/6/2023 at 9:19 AM, 2:10 PM and 2:42 PM -6/7/2023 at 8:18 AM, 8:30 AM During an observation and simultaneous interview on 6/7/2023 at 9:30 AM with Registered Nurse, Staff L, she revealed that the blinking red light indicates low pressure, that it is leaking, and not working properly. Additionally, she acknowledged that the air mattress was not set according to the physician's order. During a surveyor interview with the Director of Nursing Services on 6/7/2023 at 2:11 PM, she was unable to provide evidence that the resident had an air mattress that was working properly and set according to the doctors order.

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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

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Based on record review and staff interview, it has been determined that the pharmacist failed to report any irregularities to the attending physician, the facility's Medical Director, and the Director of Nursing Services (DNS) for 1 of 8 residents reviewed for monthly drug regime reviews, Resident ID #97. Findings are as follows: Review of the record for Resident ID #97 revealed that s/he was admitted to the facility in October of 2022 with diagnoses including, but not limited to, congestive heart failure and anxiety. Record review revealed a physician's order dated 3/15/2023 for Trazodone 100 milligram (mg) tablet to be administered as needed at bedtime for insomnia. Further review of this order failed to reveal an end date. Record review of the March 2023 Medication Administration Record revealed that the resident received the above-mentioned medication one time on 3/31/2023, after the 14-days. Review of the Pharmacist Consultation Recommendation Reports for April and May of 2023 failed to reveal evidence that the pharmacist identified that this order did not have an end date. During a surveyor interview with the Director of Nursing Services on 6/8/2023 at 1:29 PM, she revealed that she would expect the pharmacist to identify the irregularity.

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 F0810 (Tag F0810)

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 special adaptive eating equipment for residents who need them, for 1 of 4 ...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide special adaptive eating equipment for residents who need them, for 1 of 4 residents reviewed who require specialized adaptive eating equipment, Resident ID #115. Findings are as follows: Record review for the resident revealed s/he was admitted to the facility in March of 2023 with diagnoses including, but not limited to, adult failure to thrive and severe-protein calorie malnutrition. Review of the resident's care plan for nutritional status dated 3/17/2023 indicates the resident has a nutritional problem related to protein-calorie malnutrition, failure to thrive, weight change, and ascites (abnormal build-up of fluid in the abdomen). Record review revealed a physician's order dated 5/26/2023 for weighted utensils for all meals as tolerated. Additionally, review of the resident's diet slip revealed weighted utensils are to be provided. Surveyor observations revealed the resident without weighted utensils while eating his/her meals on the following dates and times: -6/6/2023 during the lunch meal -6/7/2023 during the breakfast meal and lunch meal Additionally, during the above-mentioned observations, the resident's hands were noted to be shaking and s/he was having difficulty holding the regular utensils. The resident consumed less than 10 percent of each meal served. Further surveyor observations on 6/7/2023 revealed a Nursing Assistant, Staff C, feeding the resident his/her breakfast and lunch. During a surveyor interview on 6/7/2023 at 12:53 PM with Staff C, she revealed she has been caring for the resident since his/her admission and that she provided both breakfast and lunch trays to the resident today. Staff C acknowledged that she did not provide weighted utensils for both of the resident's meals. During a surveyor interview on 6/7/2023 at 12:56 PM with Speech Therapist, Staff M, she revealed she has been working with the resident for the last few weeks for diet texture analysis. Staff M further revealed that she was unaware the resident has an order to receive weighted utensils. Additionally, Staff M revealed that the resident has been using regular utensils while she has been working with him/her. During a surveyor interview on 6/7/2023 at 1:08 PM with Licensed Practical Nurse, Staff L, she revealed the resident should have received the weighted utensils with his/her meals. Staff L further revealed that meal trays are set up by the main kitchen and sometimes they do not provide the weighted utensils on the meal trays. Additionally, Staff L revealed it is the kitchen's responsibility to ensure that the weighted utensils are on the trays as it is documented on the diet slip. During a surveyor interview on 6/7/2023 at 2:17 PM with the Director of Nursing Services (DNS) in presence of the Admissions Coordinator, she acknowledged that the resident was not provided the weighted utensils as ordered. During a surveyor interview on 6/7/2023 at 2:30 PM with the Director of Rehabilitation in the presence of the DNS, she revealed she has been working with the resident and that she saw the resident yesterday during breakfast. She further revealed the resident was offered weighted utensil and uses them approximately 50% of his/her meal. The Director of Rehabilitation indicated she wrote the order for weighted utensils with all meals, which was approved by the resident's physician on 5/26/2023. Additionally, she revealed that the resident should have received the weighted utensil with all meals and if s/he is not able to tolerate them, the resident can use the regular utensils for his/her meals. During a surveyor interview on 6/8/2023 at 11:08 AM with the Food Services Director (FSD), she revealed that the resident's trays are set up on the unit by the Nursing Assistants (NAs). The FSD further revealed that weighted utensils come from the kitchen and are sent up with the resident's meals. The NA's are the ones that set up the resident's trays and place the weighted utensils on the trays.

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

Resident Rights (Tag F0550)

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 resident and staff interview, it has been determined that the facility failed ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and resident and staff 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 16 residents observed who require total assistance from staff for hygiene, Resident ID # 95 and 2 of 10 residents observed who require total assistance from staff for feeding, Resident ID #s 115 and 173. Findings are as follows: 1. Record review revealed Resident ID #95 was admitted to the facility in October of 2017 with diagnoses including, but not limited to, autistic disorder and spastic quadriplegic cerebral palsy (a condition that causes stiff and jerky movements due to increased muscle tone and brain damage). Record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident has severe cognitive impairment. Additionally, the assessment revealed s/he requires extensive assistance for all activities of daily living (ADL) and an assist of 1 staff member for personal hygiene needs, including shaving. Record review of a care plan dated 8/16/2022 with a focus area for ADL self-care deficit related to Autism with interventions including, but not limited, to providing routine grooming every morning and provide assistance with bathing and showers. During a surveyor observation on 6/7/2023 at 2:08 PM revealed the resident was seated in a wheelchair across from the nurse's station. S/he was wearing an outfit comprised of a short sleeved shirt and shorts exposing his/her legs which were noted to be covered in thick, black hair approximately 1 inch in length. During a follow up surveyor observation and simulataneous interview on 6/8/2023 at 11:42 AM with Nursing Assistant, Staff A, revealed the resident was lying in bed with his/her legs still noted to be hairy and unshaven. Staff A acknowledged the resident's legs had thick, black hair and were unshaven. She revealed the resident receives showers twice weekly, but staff does not assist the resident in shaving. During a surveyor interview on 6/8/2023 at 11:58 AM with Licensed Practical Nurse (LPN)/Unit Manager (UM), Staff B, she acknowledged that the resident's legs had thick, black hair and were unshaven. Additionally, she revealed she is unaware if staff had attempted to contact his/her responsible party in the past regarding his/her personal hygiene and shaving his/her legs. During a surveyor interview on 6/8/2023 at 12:17 PM with the resident's designated responsible party, she revealed that she was never contacted by staff regarding shaving the resident's legs. She revealed she would prefer that the resident's leg hair be removed by a cream and not shaven. During a surveyor interview on 6/8/2023 at 12:30 PM with the Administrator in the presence of the Director of Nursing Services (DNS) she revealed that staff did not contact the resident's responsible party relative to shaving the resident's legs. Additonally, the DNS revealed she was unaware of her desire to have the hair removed from his/her legs. 2. Record review for Resident ID #115 revealed s/he was admitted to the facility in March of 2023 with diagnoses including, but not limited to adult failure to thrive and severe-protein calorie malnutrition. Review of the resident's care plan dated 3/17/2023 which indicates the resident has a nutritional problem related to protein calorie malnutrition, failure to thrive, weight change, and ascites (abnormal build-up of fluid in the abdomen) with interventions including, but not limited to, assistance with meals as needed. Surveyor observations of the resident's meals during breakfast and lunch on 6/7/2023 revealed a Nursing Assistant, Staff C, standing over the resident while feeding his/her meals. During a surveyor interview with Staff C on 6/8/2023 at 9:19 AM, she stated I'm more comfortable that way .she further revealed that she sometimes sits and sometimes stands while feeding residents. During a surveyor interview with the DNS in presence of the Admissions Coordinator on 6/8/2023 at 2:59 PM, the DNS revealed she would expect that staff sit while feeding residents. 3. Record review revealed Resident ID #173 was admitted to the facility in September of 2022 with a primary diagnosis of cerebral palsy (a group of movement disorders that appear in early childhood-signs and symptoms include poor coordination, stiff muscles, weak muscles, and tremors). Record review of a Quarterly MDS assessment dated [DATE], revealed a Brief Interview for Mental Status score of 3 out of 15, indicating that the resident has severe cognitive impairment. The MDS indicates the resident's hearing is adequate (no difficulty in normal conversation, social interaction, and listening to TV), speech is unclear (slurred) and usually understood (difficulty communicating some words to finishing thoughts but is able if prompted or given time). Further record review of the MDS revealed the resident required total assistance of 2 staff members for ADLs, including hygiene and dressing and an assist of 1 staff member for eating. Record review of the plan of care initiated on 10/8/2022 revealed the resident is dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits, immobility and physical limitations. During a surveyor observation, after entering the resident's room with LPN/UM, Staff D on 6/7/2023 at 9:45 AM, Resident ID #173 was observed lying in bed with Nursing Assistant, Staff E and the resident's roommate at the bedside. Further obseravtion revealed the curtain between the two beds were half drawn, allowing Resident ID #132 to observe Resident ID #173's exposed breasts, abdomen, thighs, legs, left arm and left shoulder. During a surveyor interview at the time of the observation, Staff D revealed staff needs Resident ID #173's roommate to assist them with interpretating. During a subsequent observation on 6/7/2023 at 10:01 AM, revealed two nursing assistants, Staff E and Staff F, transferring Resident ID #173 from his/her bed to his/her recliner chair. During the transfer, the surveyor observed from the hallway the resident's door to his/her room open and the curtain not completely drawn, with Resident ID #132 present and observing the resident being transferred. During an interview immediately following the above observation, Staff E and Staff F acknowledged the roommate was present during morning care and during the resident's transfer. Both Staff E and F revealed they needed Resident ID #132 to help with interpreting for Resident ID #173. Additionally, they revealed this practice has been going on for a while. During a surveyor interview with Staff E on 6/7/2023 at 10:07 AM, she revealed they don't understand the resident and that his/her roommate helps them to understand him/her. Staff E revealed Resident ID #173 speaks Spanish and they don't understand him/her. Staff E further revealed that they leave the curtain open when they provide care so Resident ID #132 can read Resident ID #173 lips when speaking. During a surveyor interview on 6/7/2023 at 10:09 AM with Resident ID #132 in the presence of Staff E, s/he revealed they have been roommates since Resident ID #173 was admitted . Resident ID #132 revealed s/he does not speak Spanish and that Resident D #173 can speak both Spanish and English. During this time, Staff E revealed although Resident ID #173 can speak English, they don't understand him/her. During a subsequent interview with Resident ID #132 on 6/7/2023 at 10:15 AM, s/he revealed that s/he helps staff to understand Resident ID #173 since they have become roommates and that s/he is present while staff provides morning care (which includes being uncovered during bathing, dressing and providing incontinent care). During a surveyor interview with the DNS, in the presence of the Admissions Coordinator on 6/7/2023 at 3:05 PM, the DNS stated They should not do that. During a surveyor interview with Resident ID #173 on 6/8/2023 at 8:11 AM, s/he revealed that they have been roommates since his/her admission last year. S/he further revealed that his/her roommate has been present during morning care (which includes being uncovered during bathing, dressing and providing incontinent care) for a long time, because s/he needs help when staff does not understand him/her. During a surveyor interview with the Social Worker on 6/8/2023 at 10:57 AM, she revealed that although Resident ID #173 has a BIMS score of 3 out of 15, s/he knows more about herself and knows more about what is going on around her. Additionally, s/he is not always understand by staff and Resident ID #132 helps staff understand him/her. Additional surveyor observation of Resident #173 on 6/8/2023 during breakfast revealed the resident sitting in his/her recliner chair in the dining room while Nursing Assistant, Staff H, was standing over the resident feeding him/her breakfast. During a surveyor interview with Staff D on 6/8/2023 at 9:11 AM, she also observed Staff H feeding the resident and acknowledgd that Staff H was standing over the resident while feeding him/her breakfast. During an interview on 6/8/2023 at 9:15 AM with Staff H, she acknowledged she should not stand over the resident while feeding. During a surveyor interview with the DNS, in presence of the Admissions Coordinator on 6/8/2023 at 2:59 PM, the DNS revealed that staff should not stand over the residents while feeding them.

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 F0658 (Tag F0658)

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 services provided meet professional standards of quality for 1 of 6 residents reviewed relative to a physician's order for as needed antipsychotic medication, Resident ID #125 and 1 of 4 residents reviewed for limited range of motion, Resident ID #173. Findings are as follows: 1. Record review revealed Resident ID #125 was admitted to the facility in July of 2020 with diagnoses including, but not limited to, major depressive disorder and anxiety disorder. Additionally, the resident is currently receiving Hospice services. Record review revealed a hospice recommendation dated 4/11/2023, approved by the resident's provider, to the change the resident's Trazodone order to 50 mg daily at bedtime. Record review of the April, May, and June 2023 Medication Administration Records (MAR) failed to reveal that the resident received the above medication after 4/26/2023. Additional record review revealed no order to discontinue this medication. During a surveyor interview on 6/8/2023 at 4:11 PM with Licensed Practical Nurse, Staff I, the nurse that transcribed the Trazodone orders, she was unable to explain why the above-mentioned Trazodone order was transcribed incorrectly with a stop date. 2. Record review revealed Resident ID #173 was admitted to the facility in September of 2022 with a primary diagnosis of cerebral palsy (a group of movement disorders that appear in early childhood-signs and symptoms include poor coordination, stiff muscles, weak muscles, and tremors). Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 3 out of 15, indicating that the resident has severe cognitive impairment. The MDS indicates the resident is usually understood (difficulty communicating some words to finishing thoughts but is able if prompted or given time). Further record review of the MDS revealed the resident has limited range of motion to both upper extremities. Record review revealed a physician's order dated 4/29/2023 for Right palm guard (a device used as a barrier between the fingers and palm skin to prevent injury to the palm from severe finger flexion contracture) as tolerated for comfort . Additionally, record review revealed a care plan initiated on 9/23/2023 that indicates the resident has an activities of daily living self-care performance deficit related to limited mobility with interventions including, but not limited to, wear a right palm guard as tolerated. During surveyor observations the resident was noted without his/her right palm guard on the following dated and times: -6/5/2023 at approximately 9:00 AM and 12:30 PM -6/6/2023 at 11:45 AM and 2:10 PM -6/7/2023 at 10:18 AM and 2:02 PM -6/8/2023 at 9:09 AM and 2:05 PM During a surveyor interview on 6/8/2023 at 2:11 PM with Nursing Assistant, Staff H, she revealed she was assigned to care for the resident and that she was unaware that the resident has an order to wear the right palm guard as tolerated. During a surveyor interview on 6/8/2023 at 2:18 PM with License Practical Nurse/Unit Manager, Staff D, she was unable to explain why the resident had not been wearing the palm guard for the above-mentioned days. During a subsequent interview 6/8/2023 at 2:19 PM with Nursing Assistant, Staff F, she revealed the palm guard was sent to the laundry room on Sunday (6/4/2023) between 7:00 AM - 3:00 PM shift and that they have not received it back yet. During a surveyor interview with the resident on 6/8/2023 at 2:29 PM, s/he revealed staff did not apply his/her palm guard. During a surveyor interview on 6/8/2023 at 2:30 PM, Activity Staff, Staff J, she revealed she usually provides activities on the unit and that she has not observed the resident wearing the palm guard. During surveyor observations on 6/7/2023 and 6/8/2023 revealed Staff J providing activities on the resident's unit with Resident ID #173 in attendance. During a surveyor interview 6/8/2023 at 2:41 PM with the housekeeping and laundry Manager, Staff K, he revealed laundry is done daily and if the palm guard was brought down on Sunday, it should be back by Monday. Staff K searched the laundry room and interviewed the laundry staff who revealed to him that they could not locate the palm guard. During a surveyor interview on 6/8/2023 at 2:55 PM, with the Director of Nursing Services and the Administrator, they were unable to provide evidence the resident has been wearing the palm guard as ordered.

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 8 residents reviewed for unnecessary medication, Resident ID #97. Findings are as follows: Review of the record for Resident ID #97 revealed that s/he was admitted to the facility in October of 2022 with diagnoses including, but not limited to, congestive heart failure and anxiety. Record review revealed the resident has a physician's order dated 3/15/2023 for Trazodone 100 mg (milligram) as needed at bedtime for insomnia. 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 March, April, May and June 2023 Medication Administration Records revealed that the resident received the above-mentioned medication one time on 3/31/2023, which was after 14 days from being ordered. During a surveyor interview with Licensed Practical Nurse/Unit Manager, Staff D on 6/6/2023 at 4:40 PM, she acknowledged that the above order has no end date and that the resident received the medication after 14 days from being ordered. During a surveyor interview on 6/6/2023 at 5:03 PM with the Director of Nursing Services, in the presence of the Administrator, she revealed her expectation would be that order for as needed psychotropic medication would have an end date.

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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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

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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 maintain medical records in accordance with professional standards and practices for 1 of 3 residents reviewed for offloading booties, Resident ID #3 and 1 of 3 residents reviewed for compression stockings, Resident #97. Findings are as follows: 1. Record review for Resident ID #3 revealed that s/he was admitted to the facility in January of 2023 with diagnoses including, but not limited to, pressure ulcer of sacral region (the portion of your spine between your lower back and tailbone) stage 4 (pressure ulcer-deep wound reaching the muscles, ligaments, or bones) and type two diabetes mellitus. Record review revealed a physician's order dated 3/6/2023 for bilateral cushioned booties to be worn while in bed. Surveyor observations failed to reveal evidence that the bilateral cushioned booties were worn by the resident while s/he was lying in bed on the following dates and times: - 6/7/2023 at 9:29 AM, 1:55 PM, and 3:11 PM - 6/8/2023 at approximately 8:30 AM and 11:35 AM Record review of the June 2023 Treatment Administration Record (TAR) revealed that on 6/7/2023 and 6/8/2023 the booties were documented as applied to the resident. During a surveyor interview on 6/8/2023 at 11:35 AM with the Unit Nurse Manager Staff B, she was unable to explain why the booties were signed off as applied to the residents feet on the above-mentioned dates and times. 2. Record review for Resident ID #97 revealed that s/he was admitted to the facility in October of 2022 with diagnoses including, but not limited to, congestive heart failure, lung disease and high blood pressure. Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating that the resident has intact cognition. The MDS indicates that the resident is independent with hygiene and dressing and requires only set up assistance from a staff member. Record review revealed a physician's order dated 12/26/2022 to apply TEDS (compression stockings) in the morning and to remove them at bedtime every day for compression. Surveyor observations failed to reveal evidence that the TEDS were applied to the resident on the following dates and times: - 6/6/2023 at 2:02 PM, 2:38 PM and 4:38 PM - 6/7/2023 at 10:45 AM - 6/8/2023 at 12:56 PM, 1:00 PM, and 1:07 PM Review of the June 2023 TAR revealed that the TED stockings were documented as applied to the resident and removed in the evening for the above-mentioned dates. Further review of the May 2023 TAR revealed the TED stockings were documented as applied to the resident for 31 out of 31 opportunities and removed in the evening for 29 out of 31 opportunities. Additional review of the April 2023 TAR revealed that the stockings were documented as worn by the resident for 29 out of 30 opportunities and removed in the evening for 30 out of 30 opportunities. During a surveyor interview on 6/8/2023 at 1:00 PM with the resident, the resident revealed s/he does not wear the TED stockings because s/he does not like them and that s/he has never worn them since being admitted to the facility in October of 2022. During an interview on 6/8/2023 at approximately 1:07 PM with Registered Nurse, Staff L, who usually works on this unit, she revealed that the resident does not like to wear the TED stockings, refuses to wear them, and that s/he has not worn them in a while. Additionally, she was unable to explain why she had documented that the TED stockings were applied to the resident on 6/3, 6/4, 6/7 and 6/8/2023 when in fact the resident had refused to wear the TED stockings. During a surveyor interview on 6/8/2023 at 1:09 PM with Licensed Practical Nurse/Unit Manager, Staff D, she revealed the resident refused to wear the stockings and that she has never seen the resident wear them. Staff D was unable to explain why staff inaccurately documented on the TAR that the TED stockings were applied when the resident did not wear them. During a surveyor interview on 6/8/2023 at 1:11 PM with Nursing Assistant, Staff C, who usually works on this unit, she revealed that she has never observed the resident wearing TED stockings because s/he refuses them. During a surveyor interview on 6/8/2023 at 1:20 PM with the Director of Nursing Services, she revealed that she was unaware that the resident refuses to wear the TED stockings and that s/he has not worn them for an extended period of time. Additionally, she would expect that the nursing documentation would accurately reflect the resident's status.

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

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 monitor and ensure that heat sanitization was achieved for a high temperature dish...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to monitor and ensure that heat sanitization was achieved for a high temperature dish machine and that staff utilize proper hand hygiene practices in accordance with professional standards for food service safety relative to the main kitchen. Findings are as follows: Record review of a facility policy titled, Staff Hygiene & III Food Worker states in part, .Policy: .Staff will wash their hands before they start to work in the kitchen and after .handling .dirty dishes .items with potential contamination . Record review of a facility policy titled, Dish Machine states in part, Policy: All utensils, dishware and service ware will be cleaned and sanitized prior to each use. The dish machine will be monitored prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing. Procedure: Staff should be knowledgeable in the proper usage of the dish machine in order to ensure proper and thorough cleaning and sanitizing of dishes. Dish machine temperatures should be monitored and recorded on the Dish Machine Temperature Log prior to use. Staff will report any problems (mechanical and/or temperature) with the dish machine to the Food Service Director [FSD] as soon as they have been identified . According to the State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities revised on 2/3/2023, page 660, states in part, .The following are general recommendations according to the U.S. Department of Health and Human Services, Public Health Services, Food and Drug Administration Food Code for .High Temperature Dishwasher (heat sanitization): -Wash - 150-165 degrees F; -Final Rinse - 180 degrees F . During the initial tour of the main kitchen on 6/5/2023 the following was observed: -6/5/2023 at 9:25 AM Dietary Aide, Staff N was observed rinsing and scrapping off dirty dishes, cups, and utensils with her bare hands and proceeded to load the dish machine. Staff N was then observed to walk to the opposite end of dish machine and began removing the clean dishes, cups, and utensils with her bare hands, without performing hand hygiene. During a surveyor interview immediately following the above observations on 6/5/2023 at 9:38 AM with Staff N, she acknowledged she did not wash her hands prior to touching the clean dishware after handling the dirty dishware. She revealed she should have washed her hands prior to handling the clean dishware. During a surveyor interview on 6/5/2023 at 9:38 AM with the Food Services Director (FSD), she revealed she would expect Staff N to have washed her hands prior to touching the clean dishware after handling the dirty dishware. Additional observations during the intial tour revealed the following related to the operation of the dish machine: -6/5/2023 8:20 AM revealed a dishwasher temperature log for the month of May 2023, but failed to reveal a temperature log for the month of June 2023. Therefore, the surveyor requested the temperature log for June 2023 from the FSD. -6/5/2023 at 8:45 AM in the presence of Dietary Aide, Staff O, revealed the dish machine gauge registered a temperature of 125 degrees Fahrenheit for the final rinse temperature. Surveyor observation on 6/5/2023 at 10:06 AM in the presence of Dietary Aide, Staff P, she acknowledged that the final rinse temperature of the dish machine registered at 138 degrees Fahrenheit (F). She revealed that the dish machine final rinse temperature should be around 140 degrees F. Additionally, she revealed that the transparent sticker which read, 180°F that was affixed to the final rinse temperature gauge indicated to staff that the machine may be overheating if it nears 180 degrees F. During a surveyor interview on 6/5/2023 at 10:02 AM with the FSD, she revealed the dish machine is a high temperature dish machine (heat sanitization). Record review of the June 2023 Dishwasher Temperature Log, provided to the surveyor by the FSD, on 6/5/2023 at approximately 10:30 AM, revealed the following dish machine final rinse temperatures on 6/5/2023 and were initialed by the FSD: - Breakfast: 189 degrees F - Lunch: 188 degrees F During a surveyor interview on 6/5/2023 at 10:27 AM with the FSD, she revealed that the dish machine's final rinse temperature should be at 180 degrees F. Additionally, she revealed that the final rinse temperature of the washing machine for lunch on 6/5/2023 was documented by her at approximately 10:00 AM. During a surveyor observation and simultaneous interview on 6/5/2023 at approximately 10:30 AM with the FSD revealed that the dish machine's final rinse temperature gauge registered at 138 degrees F. Additionally, she acknowledged she was not made aware that the dish machine's final rinse temperature was registering below 180 degrees F. Record review of a dish machine report document dated 6/5/2023 at 11:05 AM states in part, .Customer called about final rinse temperature. I asked her to check if booster was on. She found it turned off . During a surveyor observation on 6/5/2023 at 11:36 AM in the presence of the FSD, revealed that the dish machine final rinse temperature gauge registered at 164 degrees F. Record review of a dish machine report dated 6/5/2023 at 12:11 PM states in part, .Booster is turned up as high as possible. Temperature gauge doesn't pass 172 [degrees F] at this time .I feel the issue is with the temperature gauge and I will order and replace . During a surveyor interview on 6/7/2023 at 2:39 PM with the Administrator, she revealed she would expect that staff wash their hands prior handling clean dishware. She further revealed she would expect that the dish machine temperatures are monitored and done accordingly. She was unable to provide evidence that staff ensured accurate and timely monitoring, and recording of the dish machine temperatures and reporting dish machine problems to the FSD as per policy. Additionally, she was unable to provide evidence that the staff maintained sanitary practices in accordance with professional standards for food service safety relative to the main kitchen.

Apr 2023 4 deficiencies 1 IJ

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0698 (Tag F0698)

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 residents who require ...

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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 who require dialysis receive such services, consistent with professional standards of practice relative to having policies and procedures for dialysis care for 3 of 3 residents, not providing appropriate transportation for 1 of 3 residents, observation and assessment of access site for 2 of 3 residents, not monitoring fluid intake and for staff failing to report a resident missing dialysis appointments for 1 of 3 residents reviewed, Resident ID #'s 1, 2 and 3. Findings are as follows: 1. Review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities revised 2/3/2023 states in part, Nursing facilities .must develop dialysis specific policies/procedures, based upon current standards of practice. This includes the care of a resident receiving dialysis services whether in the facility or at an offsite location . During a surveyor interview on 4/18/2023 at approximately 12:25 PM with the Director of Nursing Services (DNS) and the Administrator they revealed that they do not have a facility policy relative to care of a resident receiving dialysis services to include, but not limited to, methods of communication between the nursing home and the dialysis center, assessing, observing and documenting care of access sites, development of comprehensive care plans and monitoring fluid and nutrition. During a surveyor interview on 4/19/2023 at approximately 11:40 AM with the Administrator, DNS and the Regional Nurse they revealed that they created a policy for dialysis after it was brought to their attention by the surveyor. 2a. Review of a community reported complaint dated 4/17/2023 received by the Department of Health alleges that Resident ID #1 missed two dialysis treatments due to the facility not securing an appropriate mode of transportation and then was admitted to the hospital. Record review of Resident ID #1 revealed that s/he was admitted to the facility in April of 2023 with a diagnosis of, but not limited to, end stage renal disease. Review of the resident's orders revealed s/he is scheduled for dialysis on Tuesday, Thursday, and Saturday every week. During a surveyor interview on 4/18/2023 at approximately 12:25 PM with the DNS and the Administrator, they revealed that the resident received his/her dialysis treatment on Saturday 4/8/2023 without any concerns. Additionally, they revealed that the resident missed his/her dialysis treatment on 4/11/2023 secondary to refusing to travel to dialysis via a wheelchair due to left hip pain. Per the DNS and the Administrator, the transport company arrived on 4/13/2023 with a wheelchair and the resident could not travel via the wheelchair due to left hip pain. Record review failed to reveal evidence that the facility staff attempted to get appropriate transportation for the resident to get to dialysis on 4/11/2023 or 4/13/2023. During a surveyor interview on 4/20/2023 at 8:55 AM with a representative from the state contracted transportation company revealed that the facility did not contact them for a level of care change or request a stretcher for transportation until 4/13/2023 after the resident had missed a second dialysis treatment. During a surveyor interview on 4/20/2023 at 11:40 AM with the facility transport aide, Staff B, he revealed that the first time he was told that the resident required a stretcher for transport to dialysis was on 4/13/2023 after s/he missed his/her second dialysis treatment. He revealed that the nursing staff did not make him aware of the residents' inability to be transported in a wheelchair due to him/her experiencing pain on 4/11/2023. Additionally, he revealed that he is the staff responsible to make such requests for changes to the transportation company. Record review reveals that facility obtained an x-ray of the left hip on 4/13/2023 for the resident's pain to the left hip. The x-ray results indicated the resident had a ltyic lesion with pathologic fracture involving the medical left acetabulum. Further record review reveals the resident was sent out to the hospital on 4/13/2023 due to the abnormal x-ray results. Record review of the hospital paperwork for Resident ID #1 dated 4/14/2023 revealed that s/he was sent to the hospital on 4/13/2023 due to a pathological fracture. S/he was found to have an altered mental status with confusion and somnolence (abnormally drowsy), decreased respirations down to 7 (normal respirations 16-20) and altered laboratory results due to missing two scheduled dialysis treatments. During a surveyor interview on 4/20/2023 at approximately 10:00 AM with the DNS and the Administrator they were unable to provide evidence that the facility attempted to obtain appropriate transportation for the resident to go to dialysis on 4/11/2023 and 4/13/2023, resulting in the resident missing two treatments. On 4/18/2023 the facility presented the surveyor with a Level of Need Assessment Form to request a stretcher for transportation to dialysis which is dated 4/11/2023. Further review of this document reveals that this document was altered as the date appeared whited out. During an interview with Registered Nurse, Staff F on 4/20/2023 at approximately 11:00 AM she acknowledged she altered the document with white out and indicated that the state contracted transportation company would have received a Level of Need Assessment Form dated 4/13/2023 not the Level of Need Assessment Form that was provided to the surveyor dated 4/11/2023. 2b. During a surveyor interview on 4/18/2023 at approximately 12:25 PM with the DNS and the Administrator, they revealed that the resident missed his/her dialysis treatment on 4/11/2023 secondary to refusing to travel to dialysis via a wheelchair due to left hip pain. Per the DNS and the Administrator, the transport company arrived on 4/13/2023 with a wheelchair and the resident could not travel via the wheelchair due to left hip pain. Record review failed to reveal evidence that the staff notified the physician after the resident missed two dialysis treatments. During a surveyor interview on 4/18/2023 at 1:55 PM with Licensed Practical Nurse (LPN), Staff C, he revealed that he worked on 4/13/2023 as the nurse for Resident ID #1. Additionally, he revealed that he did not contact the doctor to make him aware of the resident missing dialysis on 4/13/2023. During a surveyor interview on 4/18/2023 at approximately 2:00 PM with the Nurse Practitioner (NP), Staff A, he revealed that he was unaware that the resident had missed two scheduled dialysis treatments until after the resident had been admitted to the hospital. Record review revealed a Nurse to MD communication form dated 4/11/2023 that indicates the resident refused dialysis on 4/11/2023 as s/he wanted to be transported via stretcher. This form has a column for both the nurse reporting the concern and the practioner acknowledging the concern. Although, this form was dated 4/11/2023 there was no indication that the physician reviewed this communication. Review of the resident's laboratory results dated [DATE] revealed a BUN of 38 (blood urea nitrogen test is used to determine how well your kidneys are working, normal values 8 - 23), a creatinine 5.33 a critically high result (creatinine blood test measures the level of creatinine in the blood, helps determine kidney function, normal values 0.8 - 1.40) and an eGFR of 5.2 (estimated glomerular filtration rate measures how much blood the filters clean every minute based on your body size, normal value is greater than 60). Review of results from 4/13/2023 following two missed dialysis treatments revealed a BUN of 92, a creatinine 9.47 a critically high result and an eGFR of 6. During a surveyor interview on 4/19/2023 at approximately 2:00 PM with the Medical Director he revealed that the resident was sent to the hospital due to an x-ray revealing a pathological hip fracture and that he was unaware that the resident had missed two dialysis treatments. Additionally, he revealed that he and the facility utilize the Nurse to MD communication form and indicates that if he did not sign the Nurse to MD communication form dated 4/11/2023 then he was not notified of the resident missing dialysis on 4/11/2023. 2c. Record review for the resident revealed a care plan dated 4/7/2023 for the need for dialysis treatment related to kidney failure and an intervention to monitor intake and output. Record review failed to reveal evidence of fluid intake being monitored for Resident ID #1. During a surveyor interview on 4/19/2023 at approximately 9:30 AM, with LPN Staff E, she revealed that if a resident is having fluid intake and output monitored, they have an order in the electronic medical record. During a surveyor interview on 4/19/2023 at approximately 11:40 AM, with the DNS and the Administrator, they were unable to provide evidence of the resident's fluid being monitored per the care plan. 3. Review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities revised 2/3/2023 states in part, .The nursing home staff must provide immediate monitoring and documentation of the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications . A. Record review of the physicians orders for Resident ID #1 revealed s/he was scheduled for dialysis on Tuesday, Thursday and Saturday every week. Review of hospital paperwork dated 4/6/2023 revealed that the resident had an AV fistula (connection of a vein and an artery, usually in the forearm, to allow access to the vascular system for hemodialysis) in his/her left upper extremity. Further record review failed to reveal evidence that the facility was assessing, observing and documenting the care of the access site, such as auscultation (the action of listening to sounds from the heart, lungs, or other organs, typically with a stethoscope)/palpation (examine by touch) of the AV fistula to assure adequate blood flow. B. Record review of Resident ID #3 revealed that s/he was re-admitted to the facility in January of 2023 with diagnoses of, but not limited to, chronic kidney disease and dependence on renal dialysis. During a surveyor interview on 4/18/2023 at 12:04 PM, with LPN Staff D, she was unable to reveal where Resident ID # 3's access sites were located and she was unable to provide evidence of assessments or documentation of the access sites. During a surveyor interview on 4/19/2023 at approximately 9:00 AM with Resident ID #3 s/he revealed that s/he has an old access site on the right upper extremity and a new access site on the left upper extremity that is being accessed for dialysis. During a surveyor interview on 4/18/2023 at approximately 12:25 PM with the DNS and the Administrator they were unable to provide evidence that the facility was assessing, observing and documenting the care of the access sites per the regulation. Additionally, they were unable to provide evidence that a resident who requires dialysis receives such services, consistent with professional standards of practice.

SERIOUS (H) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Deficiency F0841 (Tag F0841)

A resident was harmed · This affected multiple residents

Based on record review and staff interview, it has been determined that the Medical Director failed to implement a resident care policy to coordinate care for residents who require dialysis (a life su...

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Based on record review and staff interview, it has been determined that the Medical Director failed to implement a resident care policy to coordinate care for residents who require dialysis (a life sustaining therapy that can replace the work of non-functioning kidneys) for 3 of 3 residents reviewed, Resident ID #s 1, 2, and 3. Findings are as follows: Review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities revised 2/3/2023 states in part, Nursing facilities .must develop dialysis specific policies/procedures, based upon current standards of practice. This includes the care of a resident receiving dialysis services whether in the facility or at an offsite location . Record review of the facility assessment states in part, .facility must conduct and document a facility-wide assessment to define what resources are necessary to care for its resident competently during day-to-day operations and emergencies .An admission is presented to the nursing administrative team for review to determine acuity and appropriateness of the person for admission .The staff involved in the admission decision ensures that the facility has the appropriate equipment, resources, etc. to provide care and support for the person prior to admission . During a surveyor interview on 4/18/2023 at approximately 12:25 PM with the Director of Nursing Services (DNS) and the Administrator they revealed that they do not have a facility policy relative to care of a resident receiving dialysis services to include, but not limited to, methods of communication between the nursing home and the dialysis center, assessing, observing and documenting care of access sites, development of comprehensive care plans and monitoring fluid and nutrition. Additional record review of the facility assessment last revised on 2/23/2023 revealed that dialysis residents make up 5% of the resident population. 1. Record review revealed Resident ID #3 was admitted to the facility in October of 2021 and readmitted in January of 2023 with a diagnosis including, but not limited to, dependence on dialysis as of April of 2022. 2. Record review revealed Resident ID #2 was admitted to the facility in January of 2011 and readmitted in August of 2022 with diagnoses including, but not limited to, chronic kidney disease stage 3, acute kidney failure, and a fistula (a surgical procedure usually in the arm made by connecting an artery to a vein in preparation for dialysis). Record review revealed a care plan dated 6/10/2022 indicating s/he has a fistula to his/her left arm and receives dialysis. 3. Record review revealed Resident ID #1 was admitted to the facility in March of 2023 and readmitted in April of 2023 with a diagnosis including, but not limited to, end stage renal disease. Additional record review reveals the resident had a care plan focus to monitor his/her intake. Further record review revealed s/he was dependent on renal dialysis and missed two consecutive treatments on 4/11 and 4/13/2023, as s/he was experiencing hip pain and was unable to tolerate sitting up in a wheelchair and requested a stretcher for transport to his/her dialysis treatments. Additional record review failed to reveal evidence that Resident ID #1's physician was notified that s/he had missed two consecutive dialysis treatments. Further record review failed to reveal evidence of orders for monitoring/care of the resident's dialysis site or that the resident's intake was being monitored. Additionally, the record lacks evidence that the facility staff attempted to obtain appropriate transportation for the resident to get to dialysis for treatment on 4/11/2023 or 4/13/2023. Record review of the hospital paperwork for Resident ID #1 dated 4/14/2023 revealed that s/he was sent to the hospital on 4/13/2023 due to a pathological fracture. S/he was found to have an altered mental status with confusion and somnolence (abnormally drowsy), decreased respirations down to 7 (normal respirations 16-20) and altered laboratory results due to missing two scheduled dialysis treatments. Record review failed to reveal evidence that a policy was developed and implemented to provide appropriate care, monitoring, and services for the dialysis resident population, specifically Resident ID #s 1, 2, and 3. During a surveyor interview on 4/18/2023 at 12:25 PM with the Director of Nursing Services in the presence of the Administrator, she revealed the facility does not have a facility care policy for their residents that currently receive dialysis. During a surveyor interview on 4/19/2023 at approximately 2:00 PM with the Medical Director he revealed that he was unaware that Resident ID #1 had missed two dialysis treatments. Additionally, he revealed he was unaware that the facility did not have a policy for the dialysis resident population. He further revealed he was unaware that it was his responsibility to ensure the facility developed and implemented a policy relative to the appropriate care, monitoring, and services required for the dialysis residents. (Refer to citation F698 for additional details).

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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

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Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to following physician orders for 1 of 3 residents reviewed for dialysis, Resident ID #1. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review revealed that the resident was admitted to the facility in April of 2023 with a diagnosis of, but not limited to, end stage renal disease. Record review revealed an order with a start date of 4/8/2023 for daily weights. Review of the April Medication Administration Record revealed that a daily weight was only obtained once, on 4/8/2023, indicating a weight was not obtained for 5 out of 6 opportunities (4/9, 4/10, 4/11 ,4/12, 4/13/2023). During a surveyor interview on 4/18/2023 at approximately 2:00 PM with the Nurse Practitioner, Staff A, he revealed that he ordered the daily weights for the resident to monitor him/her, because s/he had abnormal labs on 4/7/2023. Additionally, he revealed he was not aware the facility had not obtained the daily weights as ordered. During a surveyor interview on 4/19/2023 at approximately 11:40 AM with the Director of Nursing Services and the Administrator, they were unable to provide evidence that a weight was obtained daily per the Nurse Practitioner's order.

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological) to meet the needs of each resident for 1 of 3 residents reviewed, Resident ID #2. Findings are as follows: Record review of a facility policy titled, POLICY AND PROCEDURE states in part, .POLICY: It is the policy of this facility that resident shall receive medications in a safe and timely manner and in accordance with established regulations and guidelines PROCEDURE .6. Following the attempt to administer the medical record .shall be documented as administered or not administered, by the employee administering the meds). As necessary an explanation as to why the medication was not administered is then required to be documented . Further record review of a facility policy titled, .Medication Shortages/Unavailable Medications states in part, .Procedure 1. Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy .If the next available delivery causes delay or a missed dose in the resident's medication schedule, facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose .If the ordered medication is not available in the Emergency Medication Supply, the licensed facility nurse should call pharmacy's emergency answering service to speak with the registered pharmacist on duty to manage the plan of action .If the medication is unavailable from pharmacy .facility should obtain alternate physician/prescriber orders, as necessary. Record review revealed Resident ID #2 was admitted to the facility in January of 2011 and readmitted in August of 2022 with diagnoses including, but not limited to, chronic kidney disease stage 3, acute kidney failure, and a fistula (a surgical procedure usually in the arm made by connecting an artery to a vein in preparation for dialysis). Record review revealed a care plan dated 6/10/2022 indicating s/he has a fistula to his/her left arm and receives dialysis three days a week. Record review revealed a physician's order dated 3/12/2023 for [NAME]-Vite tablet (supplement for residents receiving dialysis) give 1 tablet by mouth daily at 4:00 PM. Record review of the March through April 18th, 2023 Medication Administration Records revealed the resident did not receive the above medication as it was unavailable to be given on the following dates: March: 14, 15, 17, 21, 22, 24, 25, 26, 27, 28, 29 April: 3, 4, 5, 8, 9, 11, 13, 14 Record review failed to reveal evidence that the staff notified the pharmacy or physician that the above-mentioned medication was unavailable to administer to the resident. Additionally, the record failed to reveal evidence that the staff made an attempt to obtain orders from the physician for an alternate medication per the facility policy. During a surveyor interview on 4/19/2023 at 11:40 AM with the Director of Nursing Services in the presence of the Administrator, she was unable to provide evidence that staff was able to provide pharmaceutical services to meet the needs of the resident.

Apr 2023 4 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

Comprehensive Care Plan (Tag F0656)

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 create and implement a comprehens...

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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 create and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 3 residents reviewed for refusal of care and medication non-compliance, Resident ID #1. Record review of a facility reported incident submitted to the Rhode Island Department of Health on 4/10/2023 states in part, Resident was found on floor in [his/her] room .Blood sugar read high on glucometer [a device used to measure a persons blood glucose. A high reading is indicative of a blood sugar that typically exceeds 600 milligrams(mg) per deciliter]. Resident is a diabetic .often refuses medications .admitted with DKA [Diabetic ketoacidosis - A serious complication of diabetes that can be life threatening] . Record review revealed Resident ID #1 was admitted to the facility in October of 2021 and readmitted in January of 2023 with diagnoses including, but not limited to, diabetes mellitus type 2 with ketoacidosis, hypertension (high blood pressure), depression, dysthymic disorder (long-term form of depression), and adult failure to thrive. Record review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 4 out of 15, indicating severe cognitive impairment. Record review of a nursing progress note dated 4/8/2023 revealed s/he was found on the floor in his/her room at approximately 5:00 AM. Additionally, his/her blood sugar was measured, and the glucometer indicated the blood sugar was high. The progress note further revealed s/he was then transported to an acute care hospital. Record review of the hospital documentation dated 4/8/2023 revealed the resident arrived at the hospital lethargic after a fall at the facility. It further revealed s/he was found to be dehydrated and in renal failure (kidney failure) requiring a total of 5 liters of intravenous fluids. Additionally, s/he was diagnosed with DKA which required an insulin drip for a blood sugar of 994. Furthermore, it revealed a nurse at the facility indicated that Resident ID #1 has been a long-time resident at the facility and does not take his/her medications. Additionally, the nurse revealed s/he has not taken any of his/her antihyperglycemic medications (medication to control blood glucose levels) for a long time. Review of a care plan revealed a focus area dated 6/15/2022 indicating the resident can be resistive to care and often refuses care, meals, and medications with the following interventions: - Administer medications as ordered and monitor/document side effects and effectiveness. - Caregivers to provide opportunities for positive interactions and engage in conversation with the resident when passing by. - Intervene as needed to protect the rights and safety of others, maintain a calm demeanor with the resident, and distract and relocate him/her as needed. - The resident continues to refuse medications and care. - The resident to allow psychiatry services to follow as needed. Record review failed to reveal evidence that the above-mentioned interventions were resident specific and included measurable objectives and timeframes to meet the medical, nursing, mental and psychosocial needs of the resident. Additionally, the care plan interventions for the resident's well-documented, chronic non-compliance since being added to his/her care plan on 6/15/2022 failed to incorporate interventions to encourage and promote the resident's compliance with care and medications and direct staff on how to proceed in the event of the resident's continued non-compliance to ensure his/her well-being. Additional record review of the care plan revealed a focus area dated 6/27/2022 specific to diabetes revealed interventions to administer diabetes medication as ordered and to monitor/document the effectiveness, and for fasting serum blood sugars as ordered by the doctor. Further record review of the care plan revealed these interventions to address the resident's diabetes were not being followed as evidence below: 1. Record review of the Medication Administration Records (MAR) from January 4th through April 8th of 2023 failed to reveal staff was documenting the resident's continued non-compliance of his/her diabetic medications and monitoring for effectiveness as per the care plan. Additional record review of the above MARs revealed the resident refused his/her diabetic medications a total of 176 of 373 opportunities, approximately 47% of the time. 2. Record review revealed a physician's order dated 1/28/2023 to check blood sugars once a day for 30 days for monitoring. Record review failed to reveal evidence of the results for the above-ordered fasting blood sugars for 14 of the 30 days. Furthermore, the resident did not have his/her blood sugar monitored from 2/27/2023 through 4/8/2023, the day s/he fell in the facility and was subsequently admitted to an acute care hospital for a life threatening diabetes complication, dehydration, and renal failure. During a surveyor interview on 4/11/2023 at 12:45 PM with the Director of Nursing Services in the presence of the Administrator, she was unable to provide evidence that a comprehensive person-centered care plan including measurable objectives and timeframes had been formulated and implemented to meet the needs of the resident's medical, nursing, and mental and psychosocial needs to ensure the resident's well-being. Please refer to the tag F760 for more information regarding the extent of Resident ID #1's medication non-compliance.

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 services being provid...

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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 services being provided meet professional standards of quality for 1 of 2 residents reviewed for appropriate monitoring and treatment for diabetes management. Findings are as follows: Record review of a facility policy and procedure document titled, Diabetes - Monitoring and treating. states in part, POLICY: It is the policy of this facility to monitor the diabetic status of those residents who are diabetic as per the order of the attending physician. The single most important factor in managing diabetes is achieving glucose control which can prevent many of the complications associated with diabetes. Symptoms of Hyperglycemia [high blood sugar] include .Acute = ketoacidosis (high level of ketones in the blood which affects the acid base balance of the body), decreased level of consciousness or confusion, dehydration, acute hunger or thirst, impaired cognitive function . Record review of 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 of a facility reported incident submitted to the Rhode Island Department of Health on 4/10/2023 states in part, Resident was found on floor in [his/her] room .Blood sugar read high on glucometer [a device used to measure a persons blood glucose. A high reading is indicative of a blood sugar that typically exceeds 600mg per deciliter]. Resident is a diabetic .often refuses medications .admitted with DKA [Diabetic ketoacidosis - A serious complication of diabetes that can be life threatening] . Record review revealed Resident ID #1 was admitted to the facility in October of 2021 and readmitted in January of 2023 with a diagnosis including, but not limited to, diabetes mellitus type 2 with ketoacidosis. Record review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 4 out of 15, indicating severe cognitive impairment. Record review of a nursing progress note dated 4/8/2023 revealed s/he was found on the floor in his/her room at approximately 5:00 AM. Additionally, his/her blood sugar was measured, and the glucometer indicated it was high. It further revealed s/he was then transported to an acute care hospital. Additional review of a nursing progress note dated 4/8/2023 revealed the resident was at the hospital in the Intensive Care Unit for DKA with a high blood sugar of 1000 (normal level 70-100). Record review of the hospital documentation dated 4/8/2023 revealed the resident arrived at the hospital lethargic after a fall at the facility. It further revealed s/he was found to be dehydrated and in renal failure (kidney failure) in addition to DKA which required an insulin drip for a blood sugar of 994 and a total of 5 liters of intravenous fluids. Furthermore, it revealed a nurse at the facility indicated that Resident ID #1 has been a long-time resident at the facility and does not take his/her medication. Additionally, the nurse revealed s/he has not taken any of his/her antihyperglycemic medications (medication to control blood glucose levels) for a long time. Record review of a care plan focus area dated 6/27/2022 revealed the resident has diabetes with interventions for diabetes medication as ordered by the physician and to monitor/document the effectiveness, and fasting serum blood sugars as ordered by the doctor. Additional review of the care plan revealed a focus area dated 6/15/2022 indicating the resident often refuses medications with an intervention to administer medications as ordered. Record review of the Medication Administration Records (MAR) from January 4th through April 8th of 2023 revealed that resident's diabetic medications were either refused, omitted or that the medication was not available to administer: - Insulin glargine give 13 units in the morning for diabetes: was not administered 3 of 21 opportunities. - Glimepiride 2 mg (milligram) give 3 tablets in the morning for diabetes: was not administered 6 of 14 opportunities. - Glimepiride 4 mg give 1 tablet daily for diabetes: was not administered 18 of 37 opportunities. - Glipizide ER (Extended release) 5 mg give 1 tablet daily for diabetes: was not administered 10 of 22 opportunities. - Tradjenta 5mg give 1 tablet daily for diabetes: was not administered 60 of 91 opportunities. - Metformin 500 mg give 1 tablet twice a day for diabetes: was not administered 95 of 173 opportunities. - Metformin 500 mg give 1 tablet three times a day for diabetes: 7 of 15 opportunities. Record review revealed the following physician orders relative to diabetes monitoring and management: - 10/26/2022 Hemoglobin A1C every 6 months (blood test to measure blood sugar levels over the prior 3 months, reference range 4.2% - 5.6%). - 1/5/2023 Check blood sugars two times a day. - 1/4/2023 Hemoglobin A1C one time for monitoring. Further record review failed to reveal that the Hemoglobin A1C blood test was completed as ordered on 1/4/2023. Additional record review revealed the resident's degree of glucose control was worsening as evidence by the Hemoglobin A1C blood test results below: - 9/1/2022: 6.2% (indicating increased risk of diabetes) - 10/26/2022: 6.7% (consistent with diabetes) Record review of a nursing progress note dated 1/27/2023 revealed the physician ordered an additional Hemoglobin A1C blood test to be obtained on the next lab day. Further record review failed to reveal evidence that the above-mentioned order for the Hemoglobin A1C blood test was obtained. Record review of a nursing progress note dated 2/1/2023 indicated the physician wanted the Hemoglobin A1C blood test to be obtained every 3 months. Further review of the record revealed the Hemoglobin A1C blood test to be obtained every 3 months was never transcribed. Further review of a nursing progress note dated 1/27/2023 revealed the physician also ordered the resident's fasting blood sugar to be obtained once a day for 30 days. Additional review of the record failed to reveal evidence of results for the above-ordered fasting blood sugars for 14 of the 30 days. Furthermore, the order dated 1/5/2023 to check blood sugars two times a day was discontinued without a physician's order to do so, indicating the resident did not have his/her blood sugar monitored from 2/27/2023 through 4/8/2023, resulting in the resident falling on that day and subsequently being admitted to an acute care hospital for life threatening diabetes complications, due to the failure to provide adequate monitoring and management of his/her diabetes. During a surveyor interview on 4/11/2023 at approximately 1:00 PM with the Nurse Practitioner, Staff A, he revealed he would expect the resident to have a hemoglobin A1C completed every 3 months and blood sugars monitored at least once or twice weekly. During a surveyor interview on 4/11/2023 at 12:45 PM with the Director of Nursing Services in the presence of the Administrator, she revealed the resident should have had the hemoglobin A1C labs completed every 3 months for monitoring. She was unable to provide evidence that the resident was monitored and treated appropriately relative to diabetes management.

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 F0692 (Tag F0692)

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 residents maintain accepta...

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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 residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight for 1 of 3 residents reviewed for weights, who experienced a severe weight loss, Resident ID #1. Findings are as follows: According to, State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, a weight loss of 10% or greater in 6 months is severe. Record review of a facility policy titled, .POLICY AND PROCEDURE states in part, .POLICY: It is the policy of this facility to monitor the weight of every resident on a regular basis and to carry out the appropriate interventions when necessary to assure the optimum level of health possible for the individual resident .PROCEDURE .MONTHLY WEIGHTS .2. The charge nurse will ensure that the weight provided by the aide is accurate. 3. If the resident has a 5 pound variance, the nurse and the aide will re-check the weight within 24 hours. If the resident's weight continues to show a variance, the nurse will contact the MD [Medical Doctor] and the dietician at which time appropriate orders/recommendations will be made . Record review revealed the resident was admitted to the facility in October of 2021 and readmitted in January of 2023 with diagnoses including, but not limited to, adult failure to thrive, abnormal weight loss, and dysphagia (difficulty swallowing). Record review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 4 out of 15, indicating severe cognitive impairment. Record review of a care plan focus area revealed s/he has a nutritional problem with interventions including, but not limited to, monitoring, recording, and reporting signs and symptoms of malnutrition to the MD such as significant weight loss of greater than 5% in 1 month or greater than 10% in 6 months. Additionally, it revealed the Registered Dietitian (RD) would evaluate and make recommendations. Record review revealed a physician's order dated 6/6/2022 for monthly weights for monitoring. Record review of the resident's monthly weights from 9/1/2022 through 3/1/2023 revealed the following: - 9/1/2022 140 pounds - 10/1/2022 142.2 pounds - 11/1/2022 138.8 pounds - 12/1/2022 135.4 pounds - 1/31/2023 129.6 pounds - 2/10/2023 171.0 pounds - 3/1/2023 123.2 pounds Further review of the weights revealed a total weight loss of 16.8 pounds from 9/1/2022 through 3/1/2023 indicating a 12% weight loss in 6 months. Additionally, the resident had a weight variance of 5 pounds on 3 occasions which required a reweigh within 24 hours per the facility policy to ensure accuracy. Additional review of the record failed to reveal evidence that a reweigh was obtained for the 5-pound or more weight discrepancies the resident was noted to have on 12/1/2022-1/31/2023, 1/31- 2/10/2023 and on 2/10- 3/1/2023, per the facility policy. Furthermore, the record failed to reveal evidence that the doctor or the dietitian were notified for the severe weight loss of greater than 10% in 6 months as per the care plan. During a surveyor interview on 4/11/2023 at 8:50 AM with the Unit Manager, Licensed Practical Nurse, Staff B, he revealed staff should notify the dietitian if a resident had lost or gained 5 pounds within a month. During a surveyor interview on 4/11/2023 at 9:39 AM with the dietitian, she revealed she was unaware of the resident's weight loss and would expect to have been notified. She further revealed if she was aware of the weight loss, she would have implemented interventions to address the weight loss. During a surveyor interview on 4/11/2023 at approximately 12:45 PM with the Nurse Practitioner, Staff A, he revealed he was unaware of the resident's weight loss.

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, disp...

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Based on record review and staff interview, it has been determined that the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's) to meet the needs of each resident for 1 of 3 residents reviewed, Resident ID #2. Record review of a facility policy titled, POLICY AND PROCEDURE states in part, .POLICY: It is the policy of this facility that resident shall receive medications in a safe and timely manner and in accordance with established regulations and guidelines PROCEDURE .6. Following the attempt to administer the medical record .shall be documented as administered or not administered, by the employee administering the meds). As necessary an explanation as to why the medication was not administered is then required to be documented . Further record review of a facility policy titled, .Medication Shortages/Unavailable Medications states in part, .Procedure 1. Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy .If the next available delivery causes delay or a missed dose in the resident's medication schedule, facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose .If the ordered medication is not available in the Emergency Medication Supply, the licensed facility nurse should call pharmacy's emergency answering service to speak with the registered pharmacist on duty to manage the plan of action .If the medication is unavailable from pharmacy .facility should obtain alternate physician/prescriber orders, as necessary. Record review revealed Resident ID #2 was admitted to the facility in March of 2023 with diagnoses including, but not limited to, dementia and depression. Record review of two nursing progress notes revealed the following: - 3/21/2023 The resident was admitted to the facility at 5:40 PM and sustained a fall in his/her room and returned to the hospital for evaluation. - 3/22/2023 The resident returned from the hospital at approximately 1:30 AM. Record review of the March 2023 Medication Administration Record (MAR) revealed s/he did not receive the following medications as ordered on the following dates and times: - Apixaban 5 mg give 1 tablet two times a day for blood clot: 2 doses not administered on 3/22/2023 and 3/28/2023 at 8:00 AM. - Dronabinol 2.5 mg give 2 capsules two times a day for pain: 4 doses not administered on 3/22/2023 and 3/26/2023 at 8:00 AM and 8:00 PM. - IFerex 150 mg give 1 capsule daily for low iron: 3 doses not administered on 3/22/2023, 3/23/2023, and 3/24/2023. - Pyridoxine HCL 100 mg give 1 tablet daily for immune health: 3 doses not administered on 3/22/2023, 3/23/2023, and 3/24/2023. - Sertraline HCL 100 mg give 1.5 tablets daily for depression: 1 dose not administered on 3/22/2023. - Divalproex Sodium 125 mg give 4 tablets twice a day for seizure for 30 days: 1 dose not administered on 3/22/2023 at 8:00 AM. - Metoprolol Tartrate 25 mg give 0.5 tablet every 12 hours for hypertension: 1 dose not administered on 3/22/2023 at 10:00 AM. - Potassium & Sodium Phosphates 280-160-250 mg give 1 packet two times a day for supplement: 4 morning doses not administered between 3/24/2023 through 3/27/2023. - Gabapentin 100 mg capsule give 2 capsules every 8 hours for pain for 30 days: 1 dose not administered on 3/22/2023 at 8:00 AM. Record review of the MAR notes for the above-mentioned medications revealed they were not administered to the resident due to the medications being unavailable as s/he was a new resident and that either the staff was awaiting the pharmacy to deliver the medications or awaiting a physician prescription. Record review of the facility medication emergency supply inventory list revealed that sertraline, divalproex, and gabapentin, 3 of the above-mentioned medications documented as not available, were listed as inventory in the facility's emergency supply medications. Record review failed to reveal evidence that staff notified the pharmacy that the above- mentioned medications were unavailable for the resident. Additionally, the record failed to reveal evidence that the physician or nurse practitioner were notified that the above-mentioned medications were unavailable to administer or that staff made an attempt to obtain orders for alternate medications as necessary per the facility policy. During a surveyor interview on 4/11/2023 at approximately 1:00 PM with the Administrator in the presence of the DNS, she revealed the resident was admitted to the facility and shortly after was transferred to the hospital after sustaining a fall and then returned to the facility that same night. She further revealed that staff did not complete the admission process because of the fall, and acknowledged that the medications were not available for the resident. Additionally, she was unable to provide evidence that the facility provided pharmaceutical services to meet the needs of the resident.

Apr 2023 2 deficiencies 2 IJ

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Comprehensive Care Plan (Tag F0656)

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 implement care plan interventions...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to implement care plan interventions to monitor a resident with a known history of wandering and exit seeking, which resulted in the resident leaving the building unsupervised, putting the resident at risk for serious injury or death., for 1 of 1 residents reviewed who successfully eloped from the facility, Resident ID #1. Findings are as follows: Record review of a facility policy titled, POLICY AND PROCEDURE Elopement Assessments states in part, POLICY: It is the policy of this facility to maintain a safe and secure environment for all of our residents. In order to achieve this; residents who are at risk for wandering/elopement need to be identified and a care plan developed to eliminate the risk. PROCEDURE .If the resident is determined to be at risk for elopement, then the appropriate interventions will be put in place to keep the resident safe .wander guard bracelet [device worn by a resident that sounds an audible alarm when a sensor is triggered to alert staff that a resident is attempting to exit the unit or building] and/or frequent checks, etc. and a care plan instituted . Record review revealed the resident was admitted to the facility in January of 2023 with a diagnosis including, but not limited to, dementia. Record review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status Score of 7 out of 15, indicating severe cognitive impairment. Additionally, the MDS Assessment revealed the resident had wandering behaviors that placed him/her at significant risk of getting to a potentially dangerous place (stairs or outside the facility). It further revealed the resident was not utilizing a wander guard (elopement) alarm. Further review of the admission MDS assessment dated [DATE] revealed the resident was triggered as being a wandering risk on a Care Area Assessment (CAA - a tool that is designed to assist the assessor to systematically interpret the information recorded on the MDS. Once a care area has been triggered, nursing home providers determine what to care plan for). Additionally, the CAA worksheet revealed that the resident has an actual problem related to wandering and elopement attempts and required a care plan to be implemented to address behavioral symptoms to minimize the risk of elopement and ensure the resident's safety. Record review of an admission elopement risk assessment dated [DATE] revealed the resident was at risk to wander. Further record review revealed another admission elopement risk assessment was completed on 3/23/2023 that revealed the resident was at high risk to wander. Additionally, the elopement risk assessment on 1/24/2023 indicated resident monitoring would increase should an elopement attempt occur. Record review of the following progress notes revealed the resident was exhibiting exit seeking behaviors: 1/26/2023 - Resident was confused and ambulating in the hallway entering other resident rooms, pushing on exit doors, pressing the exit door buttons, and fiddling with the fire alarms. 2/12/2023 - Resident needed redirection at the nurses station/entrance as s/he attempted to the leave the unit twice. Record review of the care plan revealed that although the elopement risk, MDS and the CAA Assessments identified that the resident had wandering behaviors and elopement attempts, a care plan was not implemented for the resident who was at risk for elopement nor were any interventions implemented to ensure Resident ID #1's safety. Record review revealed that on 4/2/2023 the resident successfully eloped from the facility. Record review of the EMS [Emergency Medical Services] Patient Care Report document dated 4/2/2023 revealed a call was received by dispatch at 11:02 PM and the unit responding to the call arrived on scene at 11:14 PM to a location near a highway, approximately 2.6 miles away from the facility and found a person (later identified as Resident ID #1) lying down on the ground with a noticeable deformity of the left leg and the left foot painfully rotated outward indicating a possible hip fracture. Additionally, the report revealed the resident had abrasions to the left elbow, right forehead, and right eye socket. It further indicated the resident arrived at the hospital at 11:31 PM. Record review of the hospital documentation dated 4/2/2023 revealed the resident had a fracture of the left hip and a subarachnoid hemorrhage (brain bleed) and subsequently underwent surgery to repair his/her left hip. During a surveyor interview on 4/5/2023 at 2:02 PM with the Director of Nursing Services, she acknowledged the CAA worksheet stating the resident was at risk for elopement and that a care plan was not initiated to prevent this resident from eloping from the facility on 4/2/2023. She revealed a care plan for elopement should have been implemented when the resident was initially identified as an elopement risk. Additional review of the resident's care plan revealed that s/he was care planned for being an elopement risk after s/he successfully eloped from the facility and sustained multiple injuries on 4/2/2023.

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, surveyor observation, 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 record review, surveyor observation, and staff interview, it has been determined that the facility failed to ensure that residents identified as an elopement risk received adequate supervision to prevent elopement from the facility for 1 of 1 residents reviewed for actual elopement, Resident ID #1. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 4/3/2023 states, .resident was attempting to elope at 6:30 PM .At 8:45 PM staff was unable to find resident .search was initiated .around 10:30 PM the temperatures were around 37 degrees and Administrator and DNS [Director of Nursing Services] decided to contact the [name redacted] Police .Between 1 AM and 2AM received a call from [name redacted] police .they have found the resident .they [facility] looked into the hospital system .resident admitted .has fractures . Record review of a facility policy titled, POLICY AND PROCEDURE Elopement Assessments states in part, POLICY: It is the policy of this facility to maintain a safe and secure environment for all of our residents. In order to achieve this; residents who are at risk for wandering/elopement need to be identified and a care plan developed to eliminate the risk. PROCEDURE .If the resident is determined to be at risk for elopement, then the appropriate interventions will be put in place to keep the resident safe .wander guard bracelet [device worn by a resident that sounds an audible alarm when a sensor is triggered to alert staff that a resident is attempting to exit the unit or building] and/or frequent checks, etc. and a care plan instituted . Record review of a facility policy titled, POLICY AND PROCEDURE .SUBJECT: Wander Guard states in part, PROCEDURE: 1. All Resident's that trigger on the elopement assessment as an elopement risk will have a wander guard bracelet place on them .2. The nurse will obtain a physician's order for wander guard placement and function daily. 3. Care plan will be updated as needed. Record review revealed the resident was admitted to the facility in January of 2023 and readmitted in March of 2023 to a semi-secured unit on the main floor with diagnoses including, but not limited to, neurocognitive disorder, dementia, and alcohol abuse. Record review of the EMS [Emergency Medical Services] Patient Care Report document dated 4/2/2023 revealed a call was received by dispatch at 11:02 PM and the unit responding to the call arrived on scene at 11:14 PM to a location near a highway, approximately 2.6 miles away from the facility and found a person (later identified as Resident ID #1) lying down on the ground with a noticeable deformity of the left leg and the left foot painfully rotated outward indicating a possible hip fracture. Additionally, the report revealed the resident had abrasions to the left elbow, right forehead, and right eye socket. It further indicated the resident arrived at the hospital at 11:31 PM. Record review of the hospital documentation dated 4/2/2023 revealed the resident had a fracture of the left hip and a subarachnoid hemorrhage (brain bleed) and subsequently underwent surgery to repair his/her left hip. Record review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status score of 7 out of 15, indicating severe cognitive impairment. Additionally, it revealed the wandering behavior of the resident placed him/her at significant risk of getting to a potentially dangerous place (stairs or outside the facility). It further revealed the resident was not utilizing a wander guard (elopement) alarm. Further review of the MDS assessment dated [DATE] revealed the resident triggered as a wandering risk on a Care Area Assessment (CAA - a tool that is designed to assist the assessor to systematically interpret the information recorded on the MDS. Once a care area has been triggered, nursing home providers determine whether or not to care plan for it). Additional review of the resident's CAA worksheet revealed that the resident has an actual problem related to wandering and elopement attempt and required a care plan to be implemented to address behavioral symptoms to minimize the risks of elopement. Additional review of the residents CAA worksheet revealed the seriousness of the behavioral symptoms documents as Resident is immediate threat to self - IMMEDIATE INTERVENTION REQUIRED .Resident is immediate threat to others - IMMEDIATE INTERVENTION REQUIRED . Furthermore, the CAA worksheet revealed the behavioral symptoms will be addressed in the care plan to minimize risks. Record review of an admission elopement risk assessment dated [DATE] revealed the resident was at risk to wander. Further record review revealed another admission elopement risk assessment was completed on 3/23/2023 that revealed the resident was at high risk to wander. Additionally, the elopement risk assessment on 1/24/2023 indicated resident monitoring would increase should an elopement attempt occur. Record review revealed the resident was exhibiting exit seeking behaviors per two nursing progress notes that revealed the following: 1/26/2023 - Resident was confused and ambulating in the hallway entering other residents rooms, pushing on exit doors, pressing the exit door buttons, and fiddling with the fire alarms. 2/12/2023 - Resident needed redirection at the nurses station/entrance as s/he attempted to the leave the unit twice. Record review failed to reveal evidence that the facility initiated a care plan or implemented any interventions to prevent elopement for the resident that was identified as at risk until 4/2/2023, the day the resident successfully eloped from the facility resulting in a hospital admission for a hip fracture and a brain bleed on 4/2/2023. Record review of several nursing progress notes dated 4/2/2023 revealed the resident attempted to elope through the main doors after a fire alarm was triggered between 6:15 PM - 6:30 PM. It further revealed 15-minute checks were implemented at 6:30 PM and the resident was noted missing from the unit at 8:45 PM. Additionally, after the initial search of the unit was unsuccessful, a code purple (facility's protocol for missing persons) was initiated. Record review of a facility provided document revealed the facility first contacted the police at 10:30 PM, approximately 2 hours from when the resident was identified as missing. During a surveyor observation on 4/4/2023 at approximately 10:45 AM of the 1st floor unit, the semi-secured unit the resident resided on, revealed the resident had access to the main entrance through the unit dining room which was unsecured. During a surveyor interview on 4/4/2023 at 8:09 AM with the Administrator, she revealed she was aware the resident was an elopement risk. She indicated the resident resided on the 1st floor which is not a locked dementia unit, referring to 1st floor as a semi-secure unit. During an additional surveyor interview on 4/4/2023 at approximately 12:00 PM with the Administrator, she revealed a resident deemed an elopement risk that resided on the 1st floor that exhibited exit seeking behaviors would be monitored or sent out. During a surveyor interview on 4/4/2023 at 10:48 AM with the Unit Manager, Licensed Practical Nurse, Staff A, he revealed the 1st floor unit is not a locked unit. He was unaware the resident was deemed an elopement risk. Additionally, he revealed the resident would have a wander guard bracelet if s/he was an elopement risk. During a subsequent surveyor interview on 4/4/2023 at 11:12 AM with Staff A, he revealed that placement on the 1st floor unit would not be appropriate for a resident that is an elopement risk. During a surveyor interview on 4/5/2023 at 1:52 PM with the Director of Nursing Services, she revealed she would expect interventions be implemented to ensure the safety of a resident identified as an elopement risk. She was unable to provide evidence that the resident received adequate supervision or interventions were implemented to prevent elopement when s/he was initially identified as an elopement risk.

Mar 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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

Based on record review, resident and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to following physician's orders for 1 of 1 resi...

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Based on record review, resident and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to following physician's orders for 1 of 1 residents reviewed, Resident ID #3. 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 that s/he was admitted to the facility in February of 2022 with diagnoses including, but are not limited to, major depressive disorder, anxiety disorder and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) Assessment completed in February 2023 revealed a Brief Interview for Mental Status Score of 15 out of 15 indicating that his/her cognition is intact. Review of a care plan initiated in 2022 stated in part, .has an ADL [activity of daily living] deficit r/t [related to] activity intolerance, fatigue. During a surveyor interview on 3/16/2023 at approximately 3:00 PM with the resident, s/he revealed that s/he has been experiencing back pain. Review of a Nursing progress note dated 11/4/2022 revealed resident was seen by the RNP [Registered Nurse Practitioner] and the following order[s] were received .consult orthopedics for back pain . Review of a physician order dated 11/4/2022 revealed orthopedic consult for back pain .please discontinue once appointment is booked. Record review of the Electronic Medication Administration Records (EMAR) from January 1st through March 16th 2023 revealed staff documented the above-mentioned order as being completed. Additional record review failed to reveal evidence that an orthopedics consult was scheduled for the resident as ordered. During a surveyor interview with the, Licensed Practical Nurse, Unit Manager on 3/16/2023 at approximately 3:30 PM, he was unable to provide evidence that an orthopedic appointment was scheduled for this resident. Furthermore, he was unable to provide evidence that the resident was offered an appointment that s/he refused to attend. During a surveyor interview on 3/16/2023 at 3:35 PM with the Director of Nursing Services in the presence of the Administrator, she acknowledged that the orthopedics appointment was not made for the resident since it was ordered in November 2022. Additional record review revealed an orthopedic appointment was scheduled for this resident on 3/16/2023, after the surveyor brought this concern to the facility's attention.

Mar 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

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 services provided by the facility...

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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 services provided by the facility failed to meet professional standards of quality relative to the use of a knee immobilizer without a physician's order for 1 of 1 resident reviewed, Resident ID #3. Findings are as follows: According to Basic Nursing, Mosby's 3rd edition, which states in part, the registered nurse checks all transcribed orders against the original order for accuracy and thoroughness. If an order seems incorrect or inappropriate, the nurse consults the physician . Review of Resident ID #3's clinical record revealed s/he was admitted to the facility in July of 2020 with diagnoses which include, but are not limited to, pain in the right knee, type 2 diabetes mellitus, and morbid (severe) obesity. Review of the resident's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15 indicating his/her cognition is intact. During a surveyor interview with the resident on 3/6/2023 at 2:04 PM, s/he revealed that s/he fell couple of weeks ago and was sent to the hospital. The resident further revealed the hospital found a fractured femur and that s/he wears a knee immobilizer daily for the bone healing process, and is not to bear weight on the right foot. Additionally, s/he indicated that the knee immobilizer is supposed to be already on, that s/he is still waiting for the NA (Nursing Assistant) to put it on. During a surveyor interview on 3/6/2023 at 2:48 PM with NA Staff A, she revealed the resident came back from the hospital with the knee immobilizer on. She further indicated that she usually applies the immobilizer on him/her and was about to apply it on him/her. Additionally, she stated she is not aware of when the immobilizer is supposed to be taken on or off. Staff A was then observed placing the knee immobilizer on the resident immediately following the interview. Review of the resident's hospital discharge document titled continuity of care consultation . dated 1/24/2023 revealed in part, .no weightbearing to right lower extremity. Knee immobilizer placed . Additional review failed to reveal a duration and a frequency for the knee immobilizer or the duration of the non-weightbearing status. Review of the resident's physician's orders failed to reveal evidence of an order for the knee immobilizer. Additional review of the orders failed to reveal the resident's non-weightbearing status. Review of the nursing progress notes revealed the following: 1/24/2023 at 11:10 PM .PT [patient] returned from hospital .[s/he] has an immobilizer in place,she is NWB [non-weightbearing] . 1/25/2023 at 7:26 PM .immobilizer is in place on [his/her] right leg . 1/27/2023 at 7:24 PM . immobilizer is in place on her right leg . 1/30/2023 at 8:30 PM .No weightbearing on right lower extremity .immobilizer is in place . 1/31/2023 at 7:58 PM .immobilizer is in place on [his/her] right leg. Resident followed no weightbearing precaution . During a surveyor interview on 3/6/2023 at 2:51 PM with Licence Practical Nurse, Staff B, she acknowledged that the resident wears the knee immobilizer, she further stated the knee immobilizer was ordered by the Nurse Practitioner but was unable to provide evidence of the order after searching in the resident's medical record. During a surveyor interview on 3/6/2023 at 3:23 PM with the Director of Nursing Services, in the presence of the Administrator, she was unable to provide evidence of a physician's order transcribed into the resident's electronic medical record for the use of the knee immobilizer. During a surveyor interview on 3/7/2023 at 10:10 AM with the Nurse Practitioner, he revealed the recommendation from the hospital is for the resident to wear the knee immobilizer continuously until the orthopedic follow-up appointment. Additionally, he further revealed the resident has missed 2 consecutive orthopedic appointments. He further indicated that the resident does not need the knee immobilizer as it places him/her at risk for developing a deep vein thrombosis [a blood clot in a deep vein of the leg] or a pulmonary embolism [blood clot in an artery of the lungs].

Feb 2023 1 deficiency 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Notification of Changes (Tag F0580)

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 immediately consult with the resi...

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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 immediately consult with the resident's physician or notify the resident's representative when there was a significant change in physical, mental, or psychosocial status for a resident who experienced a fall for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of a community reported complaint alleges in part, Pt [Patient] had an unwitnessed fall at 1 am, reportedly did not return to baseline post fall and EMS [Emergency Medical Services] was not contacted until 8:45 am. Review of a facility policy titled, Falls reduction program approved on 9/24/2021, states in part, .Residents are to be-assessed whenever they exhibit a change in status that may put them at risk for the fall .The licensed nurse on duty is responsible to institute a huddle investigation as soon after a fall as possible utilizing the input of the resident, employees and witnesses .the goal of the investigation is to identify possible contributing factors leading to a fall .the licensed nurse on duty is responsible to provide immediate care and intervention as appropriate .notify the doctor .notify the appropriate resident representative as soon as is practical . Review of an additional facility policy titled, Neurological Assessment states in part, .whenever a resident suffers an actual or a suspected head injury, that resident is to be carefully monitored at the frequency ordered by the physician for a period of no less than 3 days .record any observations noted that indicate a change from the resident's baseline. Results of the assessment above should be recorded on a neurological observation located in the electronic medical record. Record review for Resident ID #1 revealed s/he was admitted to the facility in January of 2023 with diagnoses that include, but are not limited to, acute respiratory failure with hypoxia (abnormally low level of oxygen), bipolar disorder, anxiety disorder, and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of Resident ID #1's admission Minimum Data Set (MDS) Assessment revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that his/her cognition is intact. Record review for Resident ID #1 revealed a physician's order dated 1/23/2023 for oxygen 2-4 liters via nasal cannula continuously. Record review for Resident ID #2 (Resident ID #1's roommate) revealed s/he was admitted to the facility in January of 2023 with diagnoses that include, but are not limited to, type 2 diabetes, morbid obesity, and obstructive sleep apnea (blockage in the airway while sleeping). Review of Resident ID #2's admission MDS revealed a BIMS score of 15 out of 15 indicating that his/her cognition is intact. During a surveyor interview with Resident ID #2 on 2/10/2023 at approximately 2:00 PM, s/he indicated that Resident ID #1 fell out of bed on the night of 2/9/2023 at approximately 12:30-1:00 AM. S/he revealed prior to the fall, Resident ID #1 was delusional, crawling out of his/her skin, was restless, putting his/her oxygen tubing on/off and was bouncing out of bed. Additionally, s/he indicated that staff was not coming to help him/her and so s/he gave Resident ID #1 his/her walker so that s/he could safely go to the nurses' station. Additionally, s/he revealed staff watched him/her for a while then brought him/her back to their room and put him/her to bed. Resident ID #2 further revealed that s/he saw an abrasion on Resident ID #1's forehead after s/he fell and that in the morning, s/he was unresponsive and was taken to the hospital at around 10:00 AM. Record review of a facility fall risk report completed on 2/9/2023 at 8:16 AM by Licensed Practical Nurse (LPN), Staff A, states in part, .Resident was found lying on the floor in [his/her] room at about 1:00 AM this morning. [S/he] was lying on [his/her] side. Resident was accessed [sic] and put back to bed. [S/he] denied any pain or discomfort at this time. Resident said [s/he] fell off the bed, bed lowered, vital signs taken and put back to bed .96% on RA [Room Air] . Further record review of the fall risk report indicates the resident did not have any injuries at the time of the incident, although the resident's roommate indicated the resident had a abrasion to his/her forehead after s/he fell. Additional review of the document failed to reveal evidence that Staff A had assessed the resident's mental status after the fall per the facility's policy. Review of a progress note dated 2/9/2023 at 8:19 AM, indicates that Nursing Assistant (NA), Staff B, alerted LPN, Staff C that the resident was acting strange and not at his/her baseline. Further review of the progress note revealed the resident had a fall the day before, had an abrasion to her/his right frontal lobe (front of head) and she contacted the doctor regarding this change. Review of an additional progress note dated 2/9/2023 at 10:14 AM, revealed Resident ID #1's oxygen saturation was 65% then increased to 85% (a normal oxygen saturation level is between 95% and 100%) after the head of his/her bed was raised to a 90-degree angle. The resident's oxygen saturation increased to 94% on 4 liters of oxygen. However, the note revealed that the resident wasn't at her/his baseline and was transferred to the hospital. Further record review of hospital documents for Resident ID #1 dated 2/9/2023 revealed s/he arrived at the hospital in rapid atrial (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart) fibrillation. S/he was intubated and diagnosed with acute metabolic encephalopathy (a diffuse but potentially reversible disorder of cerebral function that often impairs the state of arousal and cognitive function) and acute hypoxemic respiratory failure (severe arterial hypoxemia that is refractory to supplemental oxygen. It is caused by intrapulmonary shunting of blood resulting from airspace filling or collapse). The resident was discharged from the hospital on 2/13/2023. During a surveyor interview with LPN, Staff A on 2/10/2023 at 10:51 AM, he revealed that when he arrived at the facility on 2/8/2023 for his 11:00 PM to 7:00 AM shift, Resident ID #1 was sitting in a chair at the nurses' station without his/her oxygen on. He revealed the nurse on the 3:00 PM to 11:00 PM shift was concerned that the resident would fall and was displaying signs of agitation that evening and that was why s/he was sitting at the nurses' station. Additionally, Staff A stated that the resident was found on the floor in his room by a NA during rounds at approximately 1:00 AM. When the surveyor questioned Staff A regarding Resident ID #1's fall, he indicated that he called the doctor and left a message. He was unable to recall the name of the doctor. He stated, I think I called Dr [name redacted]. Staff A then indicated in his interview that he did not leave message for the doctor as the doctor never picked up and the phone kept ringing and ringing. He indicated that he did not make any further attempts to contact any other providers. During a surveyor interview on 2/10/2023 at 2:57 PM with the Nurse Practitioner, she revealed she did not receive a call indicating Resident ID #1 had a change in condition or a fall during the evening of 2/8/2023 or the night of 2/9/2023. She further revealed that she received a call on 2/9/2023 at approximately 9:30 AM to notify the office that the resident was being sent to hospital for a change of mental status. During a surveyor interview with the Director of Nursing (DNS) in the presence of the Administrator on 2/10/2023 at approximately 3:00 PM, they acknowledged LPN, Staff A failed to appropriately assess the resident after the fall and indicated the abrasion to the head was from the fall. During a follow up interview on 2/14/2023 at 1:35 PM with Staff A, the surveyor questioned why Resident ID #1 was not wearing his/her oxygen as ordered as documented on the fall risk report on 2/9/2023. Staff A revealed that he must have incorrectly documented on the fall risk report that Resident ID #1 was on room air. During a follow up interview with the DNS on 2/14/2023 at 2:51 PM, she acknowledged Staff A documented Resident ID #1's oxygen saturation incorrectly.

Jan 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0742 (Tag F0742)

Could have caused harm · This affected 1 resident

Based on record review, and staff interview it has been determined that the facility failed to ensure that a resident who displays or is diagnosed with a mental disorder receives appropriate treatment...

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Based on record review, and staff interview it has been determined that the facility failed to ensure that a resident who displays or is diagnosed with a mental disorder receives appropriate treatment and services to attain the highest practicable mental and psychosocial well-being for 1of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of a facility reported incident sent to the Rhode Island Department of Health on 1/24/2023 revealed that on 1/23/2023 Resident ID #1, punched another resident in the face. Record review revealed that Resident ID #1 was admitted to the facility in December of 2021 with diagnoses including, but not limited to, major depressive disorder and generalized anxiety disorder. Review of a care plan initiated on 6/20/2022 and revised on 1/23/2023 revealed s/he has the potential to be physically aggressive related to anger. The care plan identifies the intervention to be implemented is a psychiatric consult as indicated. Record review revealed the resident was seen on 1/10/2023 by a behavioral health provider and the recommendation in part was to discontinue Buspar (medication to treat anxiety order) 5 MG (milligrams) BID (two times a day) and to start Buspar 7.5 mg BID. Record review of the Medication Administration Record for January 2023 from January 11th through January 31st revealed that the resident was receiving Buspar 5 MG PO (by mouth) BID and not the recommended Buspar 7.5 MG BID. Further record review failed to reveal evidence that the recommendation from the behavioral heath care provider which should have been reviewed by the primary care provider to approve or disapprove the recommendation was not completed resulting in the resident not receiving the increased dose of Buspar to 7.5 MG. During a surveyor interview on 1/31/2023 at approximately 1:15 PM with the Nurse Practitioner (NP) he indicted that he was unaware of the recommendation that was made by the behavioral heath care provider. During a surveyor interview on 1/31/2023 at approximately 1:30 PM with the Director of Nurses she revealed the unit manager was unaware of the recommendation from the behavioral heath care provider on 1/10/2023. During an additional surveyor interview on 1/31/2023 at approximately 3:15 PM with the Director of Nurses she was unable to provide evidence that the recommendation from the behavioral heath care provider was followed up on.

Dec 2022 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

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, and staff interview, it has been determined that the facility failed to protect th...

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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 residents' right to be free from abuse for 1 of 3 residents reviewed for abuse, Resident ID #3. Findings are as follows: Record review of the facility policy titled Abuse prohibition, dated 9/24/2021, states in part, POLICY: It is the policy of this facility to ensure that all residents are treated with respect and dignity and that all residents are free abuse .DEFINITIONS .willful .sexual .abuse .includes sexual harassment .or assault . Record review of a facility reported incident sent to the Rhode Island Department of Health on 12/27/2022 indicates that an incident occurred on 12/26/2022 at 11:00 AM in the unit hallway. The report alleges in part, Abuser [alleged perpetrator, Resident ID #2] .aggressive to other residents . Abuser was touching victim's [Resident ID #3] buttock .Abuser continues to roam in other resident's room. [S/he] is unable to redirect . 1. Record review revealed that the alleged perpetrator, Resident ID #2, was admitted to the facility in December of 2022 with diagnosis that include but is not limited to, dementia with other behavioral disturbance. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition is severely impaired with short and long term memory problems. Additional record review revealed a care plan initiated on 12/8/2022 and revised on 12/27/2022 indicating that the resident has a history of being physically aggressive and has had physical altercations with other residents on 12/13/2022 and 12/24/2022. The care plan states in part, .[S/he] was the aggressor . Interventions include but are not limited to, one to one supervision as needed, If response is aggressive, staff to walk away and approach later. Additional record review of the progress notes dated 12/8/2022 through 12/27/2022 revealed the following: • 12/8/2022 at 2:55 PM .requires a higher level and 1:1 sitter .Goes in other residents rooms pulling away their blankets . • 12/13/2022 at 5:55 PM .Disrobed and wandering room to room . • 12/19/2022 at 4:36 AM .approaches Writer and says 'come over here baby' 'come with me' .intrusive in other resident rooms .Needs multiple cues to 'not touch' .not easily redirected . • 12/21/2022 at 1:57 PM .Inappropriate touching . • 12/23/2022 at 11:45 PM .presents with .intrudent behaviors, difficulty redirecting. • 12/24/2022 at 6:35 AM .[S/he] continues to go into other patients rooms .demonstrates .impulsiveness, restlessness, anxiety .Writer Observed Other residents become upset with [him/her] r/t [related to] .displayed behaviors . • 12/24/2022 at 5:47 PM .Resident found nude by aide around 3:30pm in [another resident's room/Resident ID #1] Trying to up [his/her] pants and attempting to block door . • 12/26/2022 at 5:22 AM .walking into other residents' rooms several times through the night . • 12/26/2022 at 9:29 AM .aggressive to other residents & nursing staff. Resident is touching .resident's body parts . During a surveyor interview with the 4th floor unit manager, Licensed Practical Nurse (LPN) Staff A, on 12/27/2022 at 3:00 PM, she revealed that Resident ID #2 was initially placed on one-to-one supervision when s/he was admitted to the facility, however had since come off. 2. Record review revealed Resident ID #1 was readmitted to the facility in October of 2022 with diagnoses that include but are not limited to, cerebral infarction (stroke), speech and language deficits following cerebral infarction, and Alzheimer's disease. Review of a quarterly MDS assessment dated [DATE] revealed the resident's cognition is severely impaired and s/he is never/rarely understood with short and long term memory problems. Additional record review revealed a progress note dated 12/24/2022 at 10:27 PM which indicates another resident was found without clothing in his/her room. The note further indicates that Resident ID #1 was found wearing just a shirt and an adult incontinence brief, without a blanket on. Record review of a care plan dated 12/27/2022 revealed the resident has a history of receiving physical and verbal aggression from others. Additionally, the care plan indicates the resident was not the aggressor during the above-mentioned incident on 12/24/2022. During a surveyor interview with Nursing Assistant, Staff B, on 12/28/2022 at 3:15 PM, she revealed that she witnessed Resident ID #2 to be unclothed while in Resident ID #1's room on 12/24/2022 sometime after 3:00 PM. Additionally, she indicated that the room door was partially closed, and that Resident ID #2 slammed the door in her face when she tried to open it. She further indicated that when she entered the room, Resident ID #1 was lying in bed without a blanket on and s/he was wearing a shirt and an adult incontinence brief. 3. Record review revealed Resident ID #3 was admitted to the facility in February of 2022 with diagnosis that include but is not limited to, frontotemporal neurocognitive disorder (dementia). Review of a quarterly MDS assessment dated [DATE], revealed a Brief Interview for Mental Status score of 7 out of 15, which indicates s/he has severely impaired cognition. Additional record review of a care plan dated 12/27/2022 states in part, [resident] has a history of receiving physical/verbal aggression from others related to Dementia. The care plan further indicated that the resident was involved in a resident-to-resident incident on 12/26/2022 and s/he was not the aggressor. During a surveyor interview with the 1st floor Unit Manager LPN, Staff D on 12/28/2022 at 11:15 AM, he revealed that Resident ID #2 moved to the 1st floor when s/he returned from a Geri psych hospital visit on 12/25/2022. He further indicated that the resident was sexually inappropriate with other residents. During a surveyor interview with Certified Medication Technician (CMT) Staff C, on 12/27/2022 at 3:11 PM, she revealed that she worked on 12/26/2022 during the 7:00 AM - 3:00 PM shift. Additionally, she indicated that Resident ID #2 was seen going from room to room touching other residents. During a surveyor interview with LPN Staff E, on 12/27/2022 at 3:24 PM, she revealed that Resident ID #2 was not on one-to-one supervision before s/he was witnessed touching the buttocks of Resident ID #3 on 12/26/2022. She indicated that at the start of her 7:00 AM to 3:00 PM shift on 12/26/2022, Resident ID #2 was wandering the unit. She further indicated that the resident required frequent redirection because s/he would touch other residents. She further indicated that she witnessed Resident ID #2 touch the buttocks of Resident ID #3 on the morning of 12/26/2022 sometime after 7:00 AM. Additionally, she indicated that Resident ID #3 appeared startled when Resident ID #2 touched him/her on the buttocks. She also indicated that Resident ID #2 was subsequently transferred to Geri psych for an evaluation on 12/26/2022. During a surveyor interview with the Administrator and Director of Nursing Services on 12/28/2022 at 2:00 PM, they were unable to reveal evidence that Resident ID #3 was kept free from 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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided by the facility meet professional standards of quality relative to followin...

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Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided by the facility meet professional standards of quality relative to following physician's orders for 1 of 3 residents reviewed for falls, Resident ID #4. 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 of a community reported incident sent to the Rhode Island Department of Health on 12/28/2022 alleges that the resident presented to the Emergency Department (ED) from the nursing home after experiencing shortness of breath. The report further indicates that the resident had two falls that week and was not transferred to the ED despite being on Eliquis (blood thinning medication used to prevent blood clots, may also cause increased bleeding and bruising). Additionally, the report indicates that the resident was noted to have bruising to his/her left chest wall, abdomen, and flank area. Record review revealed that the resident was admitted to the facility in August of 2020 with diagnoses that include but are not limited to, Parkinson's disease, Alzheimer's disease, and atrial fibrillation (an irregular heart rhythm that can lead to blood clots in the heart). Record review of the December 2022 Licensed Nurse Medication Administration record revealed an order dated 6/7/2020 which states in part, Resident is on Eliquis Monitor for bleeding complications .unusual bruising .Notify MD [Medical Doctor] of any changes. Review of a care plan dated 6/14/2022 with a target date of 3/23/2023 indicates that Optum(health care provider team) is to be called first. Further record review of the progress notes revealed that the resident had falls on 12/20, 12/21, 12/22/2022, and 12/26/2022. Record review of a skin observation dated 12/22/2022 at 9:49 AM revealed that the resident had facial and abdominal bruising at the time of the assessment. Additional record review of a skin observation dated 12/27/2022 5:21 PM states in part, .bruising persists to .abdominal areas . Further record review failed to reveal evidence that MD or Nurse Practitioner (NP) were notified of the bruising to the resident's abdominal area on the above-mentioned dates. Record review of a document dated 12/28/2022 at 2:40 PM titled, OPTUM authored by NP Staff F, revealed that the resident was seen for an acute follow up after nursing reported that s/he was lethargic and hypoxic (low oxygen blood levels). The note states in part, Member seen for an acute follow-up after nursing reported that patient was lethargic and hypoxic .Recent falls on 12/22/22 and 12/26/22 .On exam this morning, the member has notable bruising on [his/her] face and a hematoma on [his/her] forehead .[s/he] is on Eliquis .EMS [emergency medical services] was called given that [s/he] is on anticoagulation [blood thinning medication] .Ecchymosis [bruising] Skin: Positive Ecchymosis Notes: Noted over the forehead/temporal area. Hematoma [a bad bruise/an injury that causes blood to pool and collect under the skin] on forehead . The record failed to reveal evidence that the NP or MD were notified of the bruising to the resident's abdomen as documented on the facility skin observation on 12/22/2022 and 12/27/2022. Additional record review of the ED Provider note document dated 12/28/2022 at 4:00 PM states in part, .Extensive hematoma and bruising along L [left] flank .On exam, [s/he] has ecchymosis over the left forehead and periorbital [around the eyes] region. [S/he] also has a very large hematoma/area of ecchymosis extending over the entire left chest wall and left flank .I am concerned for the possibility of intracranial hemorrhage [bleeding inside the skull] .possible internal chest/abdominal breathing .Impression .Acute fractures of the left seventh through 10th ribs .There is a left subpleural hematoma [collection of blood within the tissue of the lungs] . During a surveyor interview with the Administrator and the Director of Nursing Services on 12/29/2022 at 2:36 PM, they indicated that the Optum NP is the resident's primary healthcare provider. Additionally, they were unable to provide evidence that the physician's order was followed relative to monitoring and reporting unusual bruising.

May 2022 10 deficiencies

CONCERN (D)

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

Comprehensive Assessments (Tag F0636)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to conduct a periodic, accurate, reproducible assessment of each resident's functional capacity for 1 of 6 r...

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Based on record review and staff interview, it has been determined that the facility failed to conduct a periodic, accurate, reproducible assessment of each resident's functional capacity for 1 of 6 residents reviewed for restraints, Resident ID #36. Findings are as follows: Record review revealed that the resident was admitted to the facility in September of 2017 and had diagnoses that include, but are not limited to, quadriplegia, neuromuscular dysfunction of bladder and injury at C5 level of cervical spinal cord. Review of a physician's order with a start date of 5/18/2018 states End side rails for end of bed Special Instructions: Ensure rails in use when resident is in bed and ensure bed in lowest position for sleep. Review of the Medication Administration Record (MAR) indicated the above-mentioned order for the dates of 5/1/2022 to 5/11/2022 was documented as used daily. Record review of Care plan with a start date of 9/16/2019 for Physical Restraints states [Name extracted] needs full upper and lower bed rails as [s/he] is a Quadriplegic and has frequent muscle spasms which have caused [him/her] to fall out of bed. The care plan additionally states in part, full bed rails will be used when [s/he] is in bed . Review of a document titled safe patient handling/ bed rail data collection dated 3/16/2022 revealed the following questions and answers, which states in part, Based on the Above Information what Level of Assist & or Device should be used with Bed Mobility? .Bilateral half rails .Is the resident able to show demonstrate how to safely lower and raise the rail(s)? .No .How does the resident benefit from the use of the rail(s)? .Enabler for Mobility. Review of the resident's quarterly Minimum Data Set (MDS, a standardized assessment for facilitating care management in nursing homes) dated 12/14/2021 and 03/16/2022 failed to reveal evidence that the resident has both bottom half side rails coded under section P on the MDS. During a surveyor interview on 05/12/2022 at approximately 12:20 PM with the Director of Nursing Services, she indicated that she would expect that the resident's MDS along with the resident's safe patient handling/bed rail data collection to match the current order and care plan for the resident. She further revealed they should be coded on the MDS in the appropriate section.

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

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 maintain acceptable parameters of nutritional status for 2 of 6 residents reviewed ...

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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to maintain acceptable parameters of nutritional status for 2 of 6 residents reviewed for weight loss, Resident ID #'s 17 and 19. Findings are as follows: Record review of a policy titled Weight Loss/Gain Protocol and Heights revealed in part .reweigh all residents who are reported to have a significant weight discrepancy in order to assess the accuracy of the weight .the reweigh shall be done within 48 hours of the initial weight .a significant weight change of 3 pounds or more in one week .a loss or gain of 5% or greater within one month . 1. Resident ID #17 was admitted to the facility in Novemebr of 2021 with diagnoses that include but are not limited to, dementia with behavioral disturbances, chronic kidney disease and major neurocognitive disorder. Record review of documeted weights for Resident ID #17 revealed the following: -4/27/2022 weight recorded at 118.2 pounds -5/11/2022 weight recorded at 111.8 pounds Further record review of progress notes from 4/12/2022 through 5/12/2022 failed to reveal evidence that the resident had a 6% weight loss in 2 weeks was addressed or a reweigh being obtained per facility policy. Additional record review of the resident's care plan that was implemented failed to address the 6% weight loss. 2. Resident ID #19 was admitted to the facility in April of 2016 with diagnoses that include but are not limited to Schizophrenia, dementia without behavioral disturbances and diabetes mellitus. Record review of documented weights for Resident ID #19 revealed the following: -4/18/2022 weight recorded at 217 pounds -5/02/2022 weight recorded at 205.2 pounds Further record review of progress notes failed to reveal evidence that the resident had a 5% weight loss in 2 weeks was addressed or a reweigh being obtained per facility policy. Additional record review of the resident's care plan that was implemented on 5/09/2022 failed to address the 5% weight loss. During a surveyor interview with the facility registered dietitian on 5/13/2022 at approximatley 9:41 AM, she acknowledged reweighs should have been done and the clinical records failed to address the weight losses.

CONCERN (D)

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

Deficiency F0694 (Tag F0694)

Could have caused harm · This affected 1 resident

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that a resident who is receiving parenteral nutrition is administered consis...

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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that a resident who is receiving parenteral nutrition is administered consistent with professional standards of practice and in accordance with physician orders for 1 of 1 resident reviewed with a PICC (peripherally inserted central catheter) line, Resident ID #14. Findings are as follows: Review of a facility policy titled Infusion Therapy 10.1 Peripheral Venous Access Devices: General Guidelines with a revision date of 1/01/2014 revealed in part, POLICY . PURPOSE To provide specific guidelines for the appropriate and safe use of Peripheral Venous Access Devices. PROCESS . 3. Transparent semi-permeable membrane dressings are recommended unless the customer has an allergy, then gauze and tape is used. 4. Protocols are followed for peripheral venous access device maintenance, including flushing and dressing changes . 6. Access device sites should be assessed as part of an ongoing systemic process to achieve desired outcomes and determine the appropriateness of therapy .Assessments should be documented and communicated to other members of the healthcare team. Recommend site assessment at a minimum every 2 hours with documentation in medical record every 8 hours. The frequency of site assessments may need to be increased based on type of therapy, customer's condition or other factors that affect the infusion therapy customer . Record review for the resident revealed that s/he was admitted to the facility in December of 2019 and had diagnoses that include but are not limited to Osteomyelitis (inflammation or swelling that occurs in the bone). Surveyor observations on the following dates and times revealed the resident with a PICC line to the right upper extremity covered with a dressing dated 4/29: - 5/09/2022 at 10:24 AM - 5/10/2022 at 12:02 PM - 5/11/2022 at 11:14 AM in the presence of Staff Nurse A, who acknowledged the dressing was dated 4/29. During a subsequent review of the resident's Medication Administration Record and physician orders in the presence of Staff Nurse A, she acknowledged that the records failed to reveal evidence of a physician's order to change the PICC site dressing, to perform any flushes, or to assess the PICC site. Staff Nurse A further indicated that the PICC line was placed on the resident on 4/21/2022. During a surveyor interview with the Director of Nursing Services on 5/12/2022 at approximately 12:16 PM, she indicated that she would expect the PICC line dressing to be changed every 3 days.

CONCERN (D)

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident's drug regimen is free from unnecessary drugs for 2 of 6 sample residents revie...

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Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident's drug regimen is free from unnecessary drugs for 2 of 6 sample residents reviewed relative to unnecessary medication, Resident ID #s 148 and 694. Findings are as follows: 1. Record review revealed Resident ID #148 was admitted to the facility in April of 2022 with a diagnosis which include but are not limited to Myocardial Infarction (heart attack). Record review of a physician's order dated 5/6/2022 states in part, Oxycodone tablet: 5 mg .special instructions: every 6 hours-prn [as needed] for moderate to severe pain . Record review of the narcotic book recording revealed Resident ID #148 received the oxycodone less than 6 hours as ordered on the following dates and times: - 5/4/2022 at 3:00 AM and next dose administered at 7:30 AM which is 4 ½ hours from last administration - 5/5/2022 at 2:00 PM and next dose administered at 6:45 PM which is 4 hours and 45 minutes from last administration - 5/11/2022 at 5:30 AM and next dose administered at 7:00 AM which is 2 ½ hours from last administration 2. Record review revealed Resident ID #694 was admitted to the facility in April of 2022 with diagnoses which include but are not limited to, malignant neoplasm of head and face (cancer of the neck and face) and unstable angina pectoris (severe pain in the chest). Record review of a physician's order dated 4/29/2022 states in part, Oxycodone 5 mg tablet every 6 hours as needed for pain . Record review of the narcotic book recording revealed Resident ID #694 received the oxycodone less than 6 hours as ordered on the following dates and times: - 5/10/2022 at 7:00 AM and next dose administered at 11:30 AM which is 4 ½ hours from last administration. During a surveyor interview on 5/12/2022 at 12:20 PM with the Director of Nursing Services, she indicated that she would expect the staff to administered the residents' medications as indicated in the orders.

CONCERN (D)

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

Unnecessary Medications (Tag F0759)

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 each resident's medication is free from medication error rates of 5% o...

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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 is free from medication error rates of 5% or greater. Based on 39 opportunities for error, there were 6 errors involving 4 residents. Resident ID #s 29, 113, 188, and 694 resulting in an error rate of 15.38%. Findings are as follows: 1. Record review revealed Resident ID #29 has the following physician's orders: - Cranberry Tablet; 450 mg [milligram] .once daily . - Ferrous Sulfate tablet; 325 mg (65 mg iron) .Take with vitamin C tablet . During a surveyor observation of the medication administration task on 5/11/2022 at 11:51 AM with the Certified Medication Technician, (CMT), Staff D, she administered Cranberry caplet 500mg with Vitamin C 60 mg instead of the 450 mg as ordered. Additionally, she was observed administering the ferrous sulfate without the Vitamin C as ordered. During a surveyor interview with the above-mentioned staff on 5/11/2022 at 2:35 PM, she acknowledged that the above-mentioned medications were not administered as ordered. 2. Record review revealed Resident ID #113 has the following physician's orders: - Cranberry Tablet; 450 mg [milligram] .once daily . - Polyethylene glycol (a medication use to treat constipation) 3350 17 GM (gram) once daily; special instructions: Give with 8 ounces of water . During a surveyor observation of the medication administration task on 5/11/2022 at 12:07 PM with the CMT, Staff D, she administered Cranberry caplet 500mg with Vitamin C 60 mg instead of the 450 mg as ordered. Additionally, she was observed administering the polyethylene glycol in 4 ounces (oz) of cranberry instead of 8oz of water as ordered. During a surveyor interview immediately following this observation with the above-mentioned staff, she acknowledged she administered the polyethylene glycol in 4oz of cranberry juice instead of the 8oz of water as ordered. During an additional interview on 5/11/2022 at 2:35 PM, she acknowledged she administered cranberry caplet 500 mg with Vitamin C 60 mg instead of the 450 mg as ordered. 3. Record review revealed Resident ID #188 has a physician's order for Miralax (polyethylene glycol 3350 powder: 17 gram/dose .special instructions: take 17 grams mixed with 8oz, water .daily . During a surveyor observation of the medication administration task on 5/11/2022 at 9:52 AM with the CMT, Staff E, she was observed mixing the Miralax in approximately 7oz of water and administered the Miralax to the resident after it was brought to her attention by the surveyor. During a surveyor interview immediately following this observation with Staff E, she acknowledged the above-mentioned observation. 4. Record review revealed Resident ID #694 has a physician's order for Oxycodone 5 mg tablet Q[every] 6 hours as needed for pain . During a surveyor observation of the medication administration task on 5/11/2022 at 8:50 AM with the nurse, Staff C, she was observed with a white tablet in a medication cup and indicated it was an oxycodone 5 mg tablet. She indicated that the tablet was taken from the medication packet that was labeled oxycodone 5 mg tablet. During a surveyor observation of the tablet in the medication cup and the medication packet, the tablet in medication cup did not match the description of the tablet in the medication packet. Staff C proceeded to attempt to administer the unknown medication to Resident ID #694 and was stopped by the surveyor. During an interview immediately following the above-mentioned observation with Staff C, she acknowledged the medication in the cup did not match the description of the medication in the packet from the pharmacy. During an additional observation and interview with a nurse, Staff F, in the presence of Staff C, she acknowledged that the tablet in the medication cup did not match the description of the tablet in the medication packet from the pharmacy. During a surveyor interview on 5/11/2022 at 9:40 AM and on 5/12/2022 at 12:20 PM with the Director of Nursing Services, she indicated that she would expect the staff to follow the physician's order. She further indicated that the medication dispensed by the nurse should match the description on the medication in the medication packet from the pharmacy.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Based on surveyor observation, and staff interview, it has been determined that the facility failed to maintain and implement an infection control program designed to provide a safe, and sanitary envi...

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Based on surveyor observation, and staff interview, it has been determined that the facility failed to maintain and implement an infection control program designed to provide a safe, and sanitary environment to help prevent the development and transmission of communicable diseases for 2 of 5 staff observed, Staff A and Staff C, related to medication administration. Findings are as follows: According to Centers for Disease Control and Prevention document dated 3/2/2011 titled, Infection Prevention during Blood Glucose Monitoring and Insulin Administration, it revealed the following: Hand Hygiene - Wear gloves during blood glucose monitoring and during any other procedure that involves potential exposure to blood or body fluids. - Change gloves between patient contacts. Change gloves that have touched potentially blood-contaminated objects or fingerstick wounds before touching clean surfaces . 1. During a surveyor observation of the nurse Staff A on 5/10/2022 at 12:00 PM, she was observed administering insulin to Resident ID #85 in front of the elevator without wearing gloves. Additionally, she was observed administering another insulin to a resident without wearing gloves on 5/10/2022 at 12:19 PM. Further observation of Staff A on 5/10/2022 at 12:18 PM revealed that she was checking two other resident's blood sugar in the common area near the elevated without wearing gloves. 2. Record review of the facility's policy and procedure titled, Maintenance and Control of the Medication Cart, revealed .Do not touch medications with your hands. During a surveyor observation of the nurse Staff C while doing the medication administration task on 5/11/2022 at 8:57 AM, she was observed to have 5 pills in the medication cup and touch them without wearing gloves. Additionally, she was observed putting the pills from the medication cup into her ungloved hand and dropped the pills on the floor in the process. Staff C picked up the pills from the floor and put it back in the medication cup. Lastly, Staff C was asked if she was ready to administer the medication to the resident and when Staff C stated yes, the surveyor asked Staff C to stop the medication administration task. During a surveyor interview with the Director of Nursing Services on 5/11/2022 at 9:40 AM, she indicated that she would expect the nurses to handle medications wearing gloves. Additionally, she indicated that medications that fall on the floor should not be administered to the resident.

CONCERN (E)

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

Deficiency F0658 (Tag F0658)

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 interviews, it has been determined that the facility has failed to ensur...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interviews, it has been determined that the facility has failed to ensure that services provided by the facility meet professional standards of quality for 1 of 3 new resident admissions reviewed and 9 of 35 residents reviewed for dietary physician orders, Resident ID #'s 14, 19, 36, 70, 84, 90, 174, 183, and 492. Findings are as follows: 1. The facility policy titled Weight Loss/Gain Protocol and Heights (undated) states in part, .For the purpose of this policy, a significant weight discrepancy is defined as: 1. A weight change of 3 pounds or more in one week .When a significant weight loss/gain is noted .Reweigh all residents who are reported to have a significant weight discrepancy in order to assess the accuracy of the weight. The reweigh shall be done within 48 hours of the initial weight . Record review revealed Resident ID #492 was admitted on [DATE] with diagnoses including, but not limited to: dementia with behavioral disturbances, vitamin D deficiency, hypertension, and Alzheimer's disease with late onset. Record review revealed Resident ID #492 was weighed on 5/05/2022 with a weight of 150 lbs. (pounds). On 5/09/2022 the resident weighed 147 lbs. There was no evidence of a reweight obtained when the 3 lbs. weight loss was documented, per policy. During an interview on 5/13/2022 at approximately 10:25 AM, the Director of Nursing acknowledged Resident ID #492 was not reweighed per facility policy. 2. Record review revealed the following physician orders and surveyor observations made on 5/09/2022 and 5/10/2022 revealed the following dietary ticket orders that arrived on the resident's meal trays: - Resident ID #14 had a physician's order with a start date of 5/06/2022 for Diet Order: CCD [consistent carbohydrate diet], NAS [no added salt], double portion meat. The resident's dietary tray ticket indicated CCD 2 GM [gram] Na [low sodium]. - Resident ID #19 had a physician's order with a start date of 5/09/2022 for Diet-CCD, NAS, with thin liquids. The resident's dietary tray ticket indicated Regular. - Resident ID #36 had a physician's order with a start date of 11/08/2019 for Diet order: house, large portion protein. The resident's dietary tray ticket indicated Regular. - Resident ID #70 had a physician's order with a start date of 7/07/2021 for Diet order: CCD, Renal diet. The resident's dietary tray ticket indicated Renal. - Resident ID #84 had a physician's order with a start date of 2/27/2022 for Diet order: House, NAS, thin liquids. The resident's dietary tray ticket indicated Regular. - Resident ID #90 had a physician's order with a start date of 3/29/2022 for Diet order: House, Dysphagia Advanced texture. The resident's dietary tray ticket indicated CCD 2 GM Na. - Resident ID #174 had a physician's order with a start date of 4/06/2022 for Diet order: CCD. The resident's dietary tray ticket indicated Regular. - Resident ID #183 had a physician's order with a start date of 7/12/2018 for Diet order: NAS thin liquids. The resident's dietary tray ticket indicated Regular. During a surveyor interview with the Administrator on 5/13/2022 at approximatley 10:30 AM, she acknowledged that the physician diet orders did not match the resident's dietary tray tickets and indicated that both should reflect the same.

CONCERN (E)

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

Respiratory Care (Tag F0695)

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 a resident who needs respiratory care is provided such care, consistent...

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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, for 2 of 4 sample residents reviewed for oxygen therapy, Resident ID #148 and #179. Findings are as follows: Record review of the facility policy titled Oxygen Administration states in part, .Check the physician's order for liter flow and method of administration . 1. Record review revealed Resident ID #148 was admitted to the facility in April of 2021 with diagnoses including, but not limited to, acute on chronic congestive heart failure (progressive heart disease that affects the pumping action of the heart muscles which causes shortness of breath), chronic respiratory failure with hypercapnia (impairment in gas exchange between the lungs and the blood causing low oxygen and high carbon dioxide), and pulmonary edema (condition where fluid accumulates in lung tissue). Record review of the resident's medication administration record (MAR) revealed an order dated 4/14/2022 that states, KEEP RESIDENTS OXYGEN SAT LEVELS/PULSE OX GREATER THAN 91%; COPD [chronic obstructive pulmonary disorder - chronic inflammatory lung disease that causes obstructed airflow from the lungs] patients greater than 90%. If below, apply supplemental oxygen via Nasal cannula[device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help] as needed. Surveyor observations of the resident's oxygen therapy revealed that on the following dates and times: -S/he was receiving 5 LPM (liters per minute) of oxygen connected to the bipap (a type of ventilator that is used to treat conditions in which a person is still able to breathe on their own, but assistance is needed) on 5/10/2022 at 11:50 AM -S/he was receiving 5 LPM of oxygen via nasal cannula on 5/11/2022 at 10:49 AM. Record review of the residents MAR failed to reveal a physician's order for liter flow. Additionally, the MAR failed to reveal evidence that oxygen was administered to the resident from 5/1/2022 - 5/11/2022. Record review of the resident's vital sign record for oxygen saturation revealed the resident received oxygen at different liter flows on the following dates: -S/he received 2 LPM of oxygen on 5/1, 5/2, 5/4, 5/5, 5/6, 5/7, 5/9, 5/10, and 5/11 of 2022 -S/he received 3 LPM of oxygen on 5/11/2022 at 8:08 AM. During a surveyor interview with the 3rd floor unit manager Staff B and Staff Nurse C on 5/12/2022 at 12:49 PM, they acknowledged that the resident did not have a physician order for oxygen liter flow. Additionally, they were unable to explain the lack of signature on the MAR for oxygen application for dates 5/1, 5/2, 5/4, 5/5, 5/6, 5/7, 5/9, 5/10, and 5/11 of 2022. 2. Record review revealed Resident ID #179 was admitted to the facility in April of 2022 with diagnoses including, but not limited to, fibromyalgia (a chronic disorder characterized by widespread musculoskeletal pain and fatigue), shortness of breath, respiratory syncytial virus (virus that cause mild cold symptoms), pneumonia, and acute and chronic respiratory failure with hypoxia (the lungs' failure to provide enough oxygen in the blood). Record review of the resident's MAR revealed an order dated 4/8/2022 that states, KEEP RESIDENTS OXYGEN SAT LEVELS/PULSE OX GREATER THAN 91%; COPD patients greater than 90%. If below, apply supplemental oxygen via Nasal cannula as needed. Surveyor observations of the resident's oxygen therapy revealed that on the following dates and times: -S/he was receiving 2 LPM of oxygen via nasal cannula on 5/10/2022 at 10:35 AM -S/he was receiving 2 LPM of oxygen via nasal cannula on 5/11/2022 at 10:36 AM -S/he was receiving 2 LPM of oxygen via nasal cannula on 5/11/2022 at 12:36 AM Further record review of the resident's MAR revealed an order dated 4/10/2022 for, BIPAP SETTINGS: INSPIRATORY PRESSURE: 12 EXPIRATORY PRESSURE: 5 BACK UP RESPIRATORY RATE: 16 TITRATE TO MAINTAIN O2 SAT > =(%): 88 At Bedtime. During a surveyor interview with the resident on 5/12/2022 at 11:08 AM, s/he indicated that a bipap has never been offered to him/her since admission. Record review of the resident's MAR revealed that the order was documented as not available on dates 4/16 - 4/22 and 4/25 - 4/29 of 2022. During an interview with the 2nd floor unit manager, she acknowledged that the resident does not have an order for flow liter of oxygen. Additionally, she acknowledged that the nurses should be documenting the resident's refusal of bipap instead of documenting not available in the MAR. During an interview with the Director or Nursing Services on 5/12/2022 at 12:39 PM, she indicated that she would expect the staff to notify the physician if the resident refuses the bipap.

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 store drugs and biologicals in accordance with currently accepted professional principles for 1 of...

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Based on surveyor observation and staff interview, it has been determined that the facility failed to store drugs and biologicals in accordance with currently accepted professional principles for 1 of 3 medication storage rooms, 6 of 7 medication carts observed, and 2 residents' rooms. Findings are as follows: Review of the facility's policy titled, Maintenance and Control of the Medication Cart states in part, .Medications are not to be left unattended on top of the cart .when a medication is discontinued, it is to be removed from the cart .the cart should be checked periodically for expired medications, if an expired medication is noted .the medication should not be given, removed from the cart .do not touch medication with your hands . 1. Surveyor observation on 5/09/2022 at 10:25 AM and on 5/12/2022 at 9:57 AM of Resident ID #151's bedside table revealed a bottle of Preservision (an eye vitamin) and a bottle of Biotin vitamins. During a surveyor interview immediately following this observation with the resident, s/he indicated that s/he self-administer's the medication and stores them at his/her bedside. 2. Surveyor observation on 5/10/2022 at 9:28 AM of Resident ID #40's bedside table revealed an Albuterol Sulfate 90 mcg (microgram) inhaler, opened, and not dated. During a surveyor interview immediately following this observation with the resident, s/he indicated that s/he self-administer's the medication and stores it at his/her bedside. 3. Surveyor observation of the 2nd floor medication cart on 5/10/2022 from 12:20 PM to 12:51 PM revealed 5 packets of medications stored on the top of the medication cart. The medication cart was observed in the hall near the dining room and adjacent to the elevator without any staff in sight. During a surveyor interview immediately following this observation with the nurse, Staff G, she acknowledged the above observation. She indicated that the medications should not have been left on the top of the medication cart. 4. Surveyor observation on 5/11/2022 at 7:49 AM of the 4th floor medication storage room refrigerator in the presence of Staff H revealed two bottles of Lorazepam Concentrate (a medication use to treat anxiety) 2MG/ML (milligram/milliliter) open and not dated. Manufacturer's instruction states in part, .Discard 90 days after first opening . During a surveyor interview immediately following this observation with Staff H, she acknowledged the two bottles of Lorazepam were opened and not dated. 5. Surveyor observation on 5/11/2022 at 8:00 AM of the 4th floor west nurse medication cart in the presence of Staff H, revealed a pack of Mucus relief 600 mg tablet with a manufacturer's expiration date of 3/22. During a surveyor interview immediately following this observation with Staff H, she acknowledged the above-mentioned medication had expired and should have been discarded. 6. Surveyor observation on 5/11/2022 at 8:57 AM of the 3rd floor nurse medication cart and narcotic book in the presence of the nurse, Staff C revealed the following: - Narcotic book with a page for Resident ID #148 indicating oxycodone 5 mg tablet with the amount on hand which states 11 tablets. Surveyor observation of the medication packet revealed 10 tablets. - Narcotic book with a page for Resident ID #695 indicating oxycodone 5 mg tablet with the amount on hand which states 21 tablets. Surveyor observation of the medication packet revealed 20 tablets. During a surveyor interview immediately following this observation with Staff C, she acknowledged the above-mentioned observation. 7. Surveyor observation on 5/11/2022 at 9:45 AM of the 1st floor nurse medication cart in the presence of the unit manager, Staff I, revealed the following: - 16 loose pills observed in the medication cart - Lorazepam 1 mg packet of 29 tablets with indication on the packet that states in part,D/C [discontinue] - Oxycodone 10 mg (a medication use to treat pain) packet of 34 tablets with indication on the packet that states in part, D/C - Pregabalin 320 mg (a medication use to treat nerve and muscle pain) packet of 9 tablets with indication on the packet that states in part, D/C - Fentanyl patch (a medication use to treat severe pain) 75 mcg (microgram) total of 9 patches with indication on the packet that states in part D/C During a surveyor interview immediately following this observation with Staff I, he acknowledged the above-mentioned observation. Additionally, he indicated that the discontinued medications should have been removed from the medication cart and destroyed. 8. Surveyor observation on 5/11/2022 at 11:29 AM of the 2nd floor north nurse medication cart in the presence of the nurse, Staff A revealed the following: - Lispro injection kwikpen U100 (a medication use to treat diabetes) with an open date of 4/13. Manufacturer instruction states in part, .throw away pen/vials after 28 days of opening . - Basaglar U100 insulin pen (a medication use to treat diabetes), open, in use, and not dated - Lispro insulin vial U100, open with an open date that is not readable During a surveyor interview immediately following this observation with Staff A, she acknowledged the above-mentioned observation. 9. Surveyor observation on 5/11/2022 at 11:39 AM of the 2nd floor west nurse medication cart in the presence the nurse, Staff G revealed a Lispro Kwikpen U100 insulin pen, opened and not dated. During a surveyor interview immediately following this observation with Staff G, she acknowledged the insulin was open and not dated. During a surveyor interview on 5/12/2022 at 12:18 PM with the Director of Nursing Services, she revealed that discontinued medications should be removed from the medication carts and destroyed. She further indicated that insulins should be dated when opened and medications should not be stored at the resident's bedside.

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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

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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 store, prepare, distribute and serve food in accordance with professional standards for food service safety. Findings are as follows: During the initial tour of the main kitchen on 5/09/2022 at approximately 10:30 AM the following observations were made: -An accumulation of dried food spills and grease were noted on a cart containing the meat slicer, the convection oven, the [NAME] (food warmer), and the tilt skillet. -A dust accumulation in screens above the steamer. -The dish machine temperatures were not recorded from 5/01/2022 through 5/09/2022. -The 3 bay sink sanitizing solution checks were not recorded from 5/01/2022 through 5/09/2022. -Food temperatures were not being recorded prior to the food leaving the kitchen from 5/01/2022 through 5/09/2022. -The Food Service Director was observed storing clean pots and pans on a kitchen rack without performing hand hygiene and donning gloves. -Staff J, Cook, was observed not wearing a beard covering on 5/09/2022 through 5/11/2022 while preparing meals. Additional surveyor observations on 5/10/2022 at approximately 1:30 PM revealed the following: - The third floor kitchenette refrigerator, used for resident food storage, had an ice pack labeled for instant cold therapy, stored with ice cream cups. -The second and third floor kitchenette refrigerators were noted to have an accumulation of brown matter on the underside of the shelving. -The open food transport carts were noted to have an accumulation of red matter spills along the grates. During a surveyor interview on 5/12/2022 at approximately 1:00 PM, the Administrator acknowledged the system breakdowns in the dietary department.

Berkshire Place

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