What is Oakland Grove Health Care Center's CMS rating?

Oakland Grove Health Care Center has a two-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Does Oakland Grove Health Care Center have any serious inspection findings?

Yes, Oakland Grove Health Care Center has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 49 total deficiencies from recent inspections.

What are the staffing levels at Oakland Grove Health Care Center?

Oakland Grove Health Care Center has a two-star staffing rating from CMS with 0.44 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is Oakland Grove Health Care Center located?

Oakland Grove Health Care Center is located in Woonsocket, RI. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does Oakland Grove Health Care Center have?

Oakland Grove Health Care Center has 178 certified beds.

Who owns Oakland Grove Health Care Center?

Oakland Grove Health Care Center is a for profit - corporation facility and is part of the ATHENA HEALTHCARE SYSTEMS chain.

Is Oakland Grove Health Care Center safe?

Oakland Grove Health Care Center has documented safety concerns including a substantiated abuse finding on record, 1 immediate jeopardy citation. Families should ask about corrective actions taken.

Do nurses at Oakland Grove Health Care Center stick around?

Oakland Grove Health Care Center has average staff turnover at 35%, which is typical for the nursing home industry.

Was Oakland Grove Health Care Center ever fined?

Yes, Oakland Grove Health Care Center has been fined $114,719 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is Oakland Grove Health Care Center on any federal watch list?

No, Oakland Grove Health Care Center 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 Oakland Grove Health Care Center?

Medicare inspectors have found 49 deficiencies at Oakland Grove Health Care Center: 1 critical, 7 serious, 40 moderate, 1 minor. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting Oakland Grove Health Care Center?

Families visiting Oakland Grove Health Care Center 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 Oakland Grove Health Care Center compare to other nursing homes?

Oakland Grove Health Care Center has a 2-star overall rating, which is below average compared to other nursing homes in RI. Families should carefully review inspection findings and consider alternatives.

Oakland Grove Health Care Center | 0/100 (Grade F)

Aug 2025 2 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, it has been determined that the facility failed to keep a resident free from physical abuse, for 1 of 4 residents reviewed, Resident ID #1.Findings are as follows:Review of a facility reported incident submitted to the Rhode Island Department of Health on 7/22/2025 revealed in part, Resident ID #2 (the perpetrator) was observed walking over to Resident ID #1 (the victim), in the dining room, and grabbed his/her left wrist, twisted it back and pulled his/her hair. Further review revealed Resident ID #2 was transferred to the hospital for a psychiatric evaluation and a STAT (immediate) X-ray was ordered for Resident ID #1.Review of a facility policy titled, RESIDENT ABUSE, NEGLECT, MISTREATMENT AND MISSAPROPRIATION PREVENTION, dated April 2015 states in part, .Each resident has the right to be free from abuse, neglect, mistreatment.'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.According to the State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities, last revised 4/25/2025, willful means that the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm.Record review revealed Resident ID #1, the victim, was admitted to the facility in May of 2025 with a diagnosis including, but not limited to, Alzheimer's disease.Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was unable to be completed, as the resident is rarely/never understood, indicating severe cognitive impairment.Record review revealed Resident ID #2, the perpetrator, was admitted to the facility in July of 2025 with a diagnosis including, but not limited to, severe dementia with agitation.Review of an MDS assessment dated [DATE] revealed a BIMS was unable to be completed, as the resident is rarely/never understood, indicating severe cognitive impairment. Further review revealed Resident ID #2 displayed wandering and physical behavioral symptoms directed towards others, 1 to 3 days, during the 7-day look back period.Record review of a care plan last revised on 7/24/2025, for Resident ID #2, revealed s/he has a history of violent and aggressive behaviors and was involved in an altercation with a resident on 7/15/2025 and with Resident ID #1 on 7/22/2025. Record review for Resident ID #2 revealed a progress note dated 7/22/2025 which revealed Resident ID #2 was in the dining room when s/he approached Resident ID #1, grabbed him/her by the left wrist, twisted his/her left wrist, and pulled his/her hair. Further review revealed Resident ID #2 was placed on a 1 to 1 with staff for safety and was sent to the hospital for a psychiatric evaluation.Further record review for Resident ID #2 revealed a progress note dated 7/23/2025 which revealed s/he was admitted to geriatric psych at the hospital, on an emergency certification (a process that allows a physician to apply for the certification of a person who is believed to need immediate care due to psychiatric disability).Additional record review for Resident ID #2 revealed that earlier in the day on 7/22/2025, at approximately 2:21 PM, staff were attempting to redirect him/her from another resident's room, when Resident ID #2 responded by striking a Nursing Assistant in the chest.Record review for Resident ID #1 revealed the following progress notes: - 7/22/2025 at 9:56 PM, revealed Resident ID #1 was eating dinner in the dining room, when Resident ID #2 approached him/her, grabbed him/her by the left wrist, twisted his/her left wrist, and pulled his/her hair. Further review revealed Resident ID #1 did not do anything to provoke this incident. Additionally, upon initial assessment, no injuries were noted, however Resident ID #1 was administered Tylenol, 650 milligrams for left wrist pain, and a STAT X-ray of his/her left wrist was ordered, to rule out injury.- 7/23/2025 at 7:45 AM, revealed Resident ID #1 was noted to be guarding his/her left wrist/hand area and a bruise measuring approximately 1.5 x 2 inches was noted to be on his/her right hand.- 7/23/2025 at 10:39 PM, revealed that the following the physical altercation with Resident ID #2, the resident sustained a wrist fracture and was transported to the hospital.- 7/24/2025 at 1:22 AM, revealed Resident ID #1 returned to the facility with a diagnosis of a left distal radial fracture (wrist fracture) and a volar splint (a medical device used to immobilize and support the wrist and hand, particularly for injuries or conditions affecting the palm or volar aspect of the hand) was applied, with instructions to follow up with an orthopedic surgeon.During a surveyor interview on 8/6/2025 at 10:58 AM, with Nursing Assistant, Staff A, she revealed that she was in the dining room and witnessed Resident ID #2 approach Resident ID #1 at his/her table and attempted to take his/her food. She revealed that when she attempted to redirect Resident ID #2 away from Resident ID #1, Resident ID #2 reacted by grabbing Resident ID #1's wrist and twisted it, causing Resident ID #1 to scream. Further, she revealed that it took three staff members to separate Resident ID #2 from Resident ID #1, due to Resident ID #2 having a tight grip on Resident ID #1's wrist and s/he would not let go. Additionally, she revealed that Resident ID #2 has a history of being combative with staff, indicating that s/he can be unprovoked at times.During a surveyor observation and interview on 8/6/2025 at 1:00 PM, Resident ID #1 was noted to be sitting in the dining room, and a splint was observed on his/her left wrist. The resident was nonsensical in the interview and when asked how s/he was doing by the surveyor, s/he responded, I can do this another day.During a surveyor interview on 8/6/2025 at 1:07 PM, with the Director of Nursing Services, she revealed that Resident ID #2 would wander around the unit and touch things, indicating s/he required frequent redirection. She revealed that during this incident, Resident ID #2 attempted to touch Resident ID #1's meal tray, and when staff attempted to redirect Resident ID #2, s/he had a quick response and grabbed Resident ID #1's wrist and twisted it, resulting in a fracture. Additionally, she was unable to provide evidence that the facility kept Resident ID #1 free from physical abuse on 7/22/2025.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional s...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to 1 of 1 resident reviewed for a splint, Resident ID #1.Findings are as follows:Review of a facility policy titled, SPLINTS/ORTHOTICS/PROSTHETICS, dated April 2015 states in part, .Upon admission/readmission, and at least every shift, all residents with a splint.will have the affected extremity monitored for circulation, motion and sensation [CSM] as well as any signs of edema [swelling], redness, irritation, or pressure areas potentially caused by the device.Nursing staff will remove the device and notify the physician and the rehabilitation department if the resident has actual or potential alteration in skin integrity that may have been caused by the device.Document evaluations and notify MD [medical doctor] of any abnormalities.Record review revealed Resident ID #1 was admitted to the facility in May of 2025 with a diagnosis including, but not limited to, Alzheimer's disease.Record review of progress notes revealed the resident sustained a distal radial (wrist) fracture of his/her left hand, following a physical altercation with another resident on 7/22/2025.Further record review revealed the resident was transferred to the hospital on 7/23/2025 to obtain a splint for his/her left wrist and returned on 7/24/2025 with a volar splint (a medical device used to immobilize and support the wrist and hand, particularly for injuries or conditions affecting the palm or volar aspect of the hand).Record review failed to reveal evidence of physician's orders relative to monitoring for CSM and skin integrity, each shift, per the facility policy.During a surveyor observation on 8/6/2025 at 12:55 PM, the resident was observed with a volar splint, wrapped in an ACE bandage, on his/her left wrist.During surveyor interviews on 8/6/2025 at 12:30 PM and 12:52 PM, with Licensed Practical Nurse, Staff B, she acknowledged that there are not any physician's orders in place to monitor for CSM and skin integrity, relative to the splint, and indicated that there should be. During surveyor interviews on 8/6/2025 at 1:07 PM and 1:36 PM, with the Director of Nursing Services, she revealed that the resident sustained a wrist fracture on 7/22/2025, requiring a volar splint and indicated that the splint is to remain in place until the resident is seen by an orthopedic surgeon on 8/12/2025. She revealed that she would have expected physician's order to be in place relative to the usage of the splint and for monitoring skin integrity and CSM.During a surveyor interview on 8/6/2025 at 1:39 PM, with the resident's provider, she acknowledged that there are no current orders in place to monitor for CSM and skin integrity relative to the splint and indicated that there should be an order to monitor for skin integrity, but would not confirm if an order should be implemented relative to CSM, as indicated in the facility's policy. Record review revealed the following physician's orders that were implemented on 8/6/2025, 13 days after the resident returned to the facility with a splint, and after it was brought to facility's attention by the surveyor:- Monitor left upper extremity and left lower extremity for CSM, every shift, for left wrist fracture and soft splint.- Monitor skin integrity of left hand, wrist and arm, every shift, for left wrist fracture and soft splint for 30 days.

Jun 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0578 (Tag F0578)

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 honor a resident's right to reque...

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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 honor a resident's right to request treatment for 1 of 1 resident reviewed for a hospital transfer, Resident ID #1. Findings are as follows: Review of a community reported complaint received by the Rhode Island Department of Health on 5/30/2025 alleged that Resident ID #1 requested to be sent out to the hospital for pain, however the facility refused the request because there was no order from a physician. Additionally Resident ID #1 called 911 from her/his personal cell phone and was transported to the hospital where a significant injury was identified. Record review revealed the resident was admitted to the facility in January of 2025 with diagnoses including, but not limited to, stroke, renal disease, and diabetes. Record review of a Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 15 out of 15, indicating s/he is cognitively intact. Further review of the MDS revealed the resident requires the assistance of a walker to move around the facility. Record review revealed the following nursing progress notes: -5/29/2025 at 12:09 AM - the resident had an unwitnessed fall and was found lying on the bathroom floor of his/her room at approximately 11:00 PM on 5/28/2025. -5/29/2025 at 3:58 AM - the resident has been requesting to be transported to the hospital since the fall. Further review of the progress note revealed the Medical Director had been notified of the fall and did not give an order to send the resident out. -5/29/2025 at 10:50 PM - the resident called 911 from his/her personal phone for transportation to the hospital for pain in his/her groin and ribs. Further review revealed the resident was transported to the hospital by Emergency Medical Services on 5/29/2025 at 11:30 PM. Review of the hospital summary of care report dated 5/30/2025 revealed that the resident had been diagnosed with a closed fracture of the first lumbar vertebra (a bone in the spine) and a rib fracture. Further review revealed s/he was discharged back to the facility on 5/30/2025. During a surveyor interview on 6/2/2025 at approximately 1:55 PM with the Director of Nursing Services (DNS), she revealed that the expectation is to contact the physician if a resident complains of pain and acknowledged that she would have called for a hospital evaluation if the resident complained of pain. Additionally, she was unable to provide evidence that the facility honored the resident's request to be transferred to the hospital.

Dec 2024 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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

Based on record review and staff interview it has been determined that the facility failed to maintain the resident's medical record in accordance with accepted professional standards and practices, f...

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Based on record review and staff interview it has been determined that the facility failed to maintain the resident's medical record in accordance with accepted professional standards and practices, for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: Record review of two community reported complaints, both submitted to the Rhode Island Department of Health on 12/2/2024, allege that Resident ID #1 had been hospitalized and that the resident did not receive his/her prescribed antibiotic therapy at the facility after s/he was discharged from the hospital. Record review revealed Resident ID #1 was readmitted to the facility in November of 2024 with diagnoses including, but not limited to, hypernatremia, dehydration, and sepsis pneumonia. Record review of the hospital Continuity of Care document dated 11/27/2024 revealed a physician's order to continue Amoxicillin-Pot Clavulanate (an antibiotic) Oral Suspension Reconstituted 250-62.5 milligram (MG)/5 milliliters (ML) two times a day for sepsis, for 3 days. Record review of a physician's order dated 11/28/2024 revealed an order for Amoxicillin-Pot Clavulanate (antibiotic) Oral Suspension Reconstituted 250-62.5MG/5ML two times a day to be given at 8:00 AM and 8:00 PM for a diagnosis of sepsis. Record review of the November 2024 Medication Administration Record (MAR) revealed the above-mentioned medication was documented as being administered to the resident on 11/28 at 8:00 AM, by Licensed Practical Nurse, Staff A. Further review of the November 2024 MAR revealed the order for Amoxicillin-Pot Clavulanate (antibiotic) Oral Suspension Reconstituted 250-62.5MG/5ML was documented as being unavailable for administration on 11/28 at 8:00 PM and 11/29/2024 at 8:00 AM. During a surveyor interview on 12/5/2024 at 1:02 PM with Staff A, she was unable to recall if she administered the above-mentioned antibiotic to the resident on 11/28/2024, as was documented in the resident's record. She further revealed that this medication is not in the facility's emergency kit and was unaware of when the pharmacy had delivered the medication to the facility. During a surveyor interview on 12/5/2024 at 11:36 AM with the Director of Nursing Services (DNS), she revealed she was unsure how Staff A would have been able to administer the antibiotic to the resident on 11/28/2024, as it was not available in the facility until 11/29/2024. Cross reference F 658

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 record review and staff interview, it has been determined that the facility failed to ensure that residents receive tre...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to following physician orders for antibiotic therapy and an for monitoring the output of an indwelling foley catheter (a device that drains urine from your urinary bladder into a collection bag outside of your body when you can't urinate on your own), for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: Record review of two community reported complaints, both submitted to the Rhode Island Department of Health on 12/2/2024, allege that Resident ID #1 had been hospitalized 4 times in less than a month and was readmitted to the facility in November of 2024 with diagnoses of hypernatremia (sodium levels in the blood being too high. Common causes include inadequate fluid intake, or fluid loss), dehydration and sepsis pneumonia (a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs caused by pneumonia). Additionally, the complaints allege that the resident did not receive the prescribed antibiotic therapy at the facility after s/he was discharged from the hospital. Further review of the complaints allege that a family member found the resident to be non-responsive and requested additional hydration on 11/28/2024, and on 11/29/2024 was gray unresponsive and requested the resident to be sent to the hospital on [DATE]. A. According to Mosby's 4th Edition, Fundamentals of Nursing page 314, states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm the clients. Record review revealed Resident ID #1 was readmitted to the facility in November of 2024 with diagnoses including, but not limited to, hypernatremia, dehydration, and sepsis pneumonia. Record review of the hospital Continuity of Care document dated 11/27/2024 revealed a physician's order to continue Amoxicillin-Pot Clavulanate (an antibiotic) Oral Suspension Reconstituted 250-62.5 milligram (MG)/5 milliliters (ML) two times a day for sepsis, for 3 days. Record review of a physician's order dated 11/28/2024 revealed an order for Amoxicillin-Pot Clavulanate (antibiotic) Oral Suspension Reconstituted 250-62.5MG/5ML two times a day to be given at 8:00 AM and 8:00 PM for a diagnosis of sepsis. Record review of the November 2024 Medication Administration Record revealed the above-mentioned medication was documented as being administered on 11/28 at 8:00 AM and then was documented as being unavailable for administration on 11/28 at 8:00 PM and 11/29/2024 at 8:00 AM. Record review of a Orders-Administration Note on 11/29/2024 at 8:41 AM revealed that it was reported to the physician that the above-mentioned medication would not be delivered from the pharmacy until later that night. Record review of a nursing progress note dated 11/29/2024 at 9:52 AM revealed that the resident had a change in condition, s/he was lethargic and noted to be wheezing, and foaming at the mouth. Record review of a nursing progress note dated 11/29/2024 at 10:57 AM revealed that the family requested that the resident be sent to the hospital. Additionally, the progress note revealed a new order from the facility's Nurse Practitioner for the resident to be sent to the hospital and 911 was called. Record review of a hospital document dated 11/29/2024 titled, Assessment states, .Patient found by [family member] to be lethargic and non responsive in the nursing home. Noted concentrated urine .Laboratory results at presentation significant for hypernatremia and acute kidney injury .Cannot exclude incomplete treatment of pneumonia as a factor noting that [the resident] missed antibiotic doses. During a surveyor interview on 12/4/2024 at 2:20 PM with the facility's Physician, he revealed that it would be his expectation to be contacted immediately if a medication was unavailable in order to select an alternative treatment and not after several doses been missed. He further revealed that he was unaware that the resident had missed doses of his/her antibiotic on 11/28/2024 and 11/29/2024. During a surveyor interview on 12/5/2024 at 11:36 AM with the Director of Nursing Services (DNS), she revealed she was unsure how the staff would have been able to administer the antibiotic to the resident on 11/28/2024, as it was not available in the facility until 11/29/2024. B. Record review of a facility policy titled Intake and Output Monitoring dated 4/2015, states in part, Intake and/or Output will be monitored as indicated by the resident's hydration status, risk for dehydration, diagnoses, and/or per physician's order . According to [NAME] Course Point Enhanced for Taylor's Fundamentals of Nursing, 9th Edition, the following are important nursing measures used to care for patients with an indwelling catheter: .make sure that the patient maintains a generous fluid intake, unless contraindicated by other health concerns. This helps prevent infection and irrigates the catheter naturally by increasing urine output .note and record the amount of urine on the patient's intake-and-output record every 8 hours . Record review of a physician's order dated 11/27/2024 revealed an order to document the resident's intake and output, every shift for 72 hours. Record review of the resident's care plan revealed that s/he has a foley catheter with interventions including, but not limited to, Monitor output for odor, color, consistency, amount, blood and sediment . Record review failed to reveal evidence that the resident's urine output was being documentation per the physician's order. During a surveyor interview on 12/4/2024 at 11:30 AM with Registered Nurse, Staff B, he acknowledged that there was no documentation of the resident's output being monitored from his/her last readmission from 11/27/2024 through 11/29/2024 or since the resident's current admission on [DATE]. During a surveyor interview on 12/4/2024 at 1:30 PM with the DNS, she acknowledged that the resident has a foley catheter. Additionally, she was unable to provide evidence that the resident's output was being monitored according to the physician's order, facility policy, and the care plan. Cross reference F 842

CONCERN (E) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

**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 maintain a...

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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 maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to Enhanced Barrier Precautions (EBP; involves using a gown and gloves during high-contact resident care activities), an enteral feeding (a method of delivering nutrition directly into the gastrointestinal tract through a feeding tube) syringe and the storage of a nebulizer mask, for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: Review of a facility policy titled, Enhanced Barrier Precautions Policy states in part, Enhanced Barrier precautions require the use of a gown and gloves for certain residents during high-contact resident care activities .High-contact resident care activities include bathing/showering, providing hygiene, dressing, transferring, linen changes, toileting, device care and wound care . Enhanced Barrier precautions will also be implemented for residents with wounds, or indwelling medical devices ( catheter, feeding tube, etc.) .Signage will be posted on the door or wall outside of the residents room indicating the need for enhanced barrier precautions, the required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves . A. Record review revealed the resident was readmitted to the facility in November of 2024 with diagnoses including, but not limited to, hypernatremia (sodium levels in the blood being too high. Common causes include inadequate fluid intake, or fluid loss), dehydration and sepsis pneumonia (a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs caused by pneumonia). Record review revealed a care plan with a revision date of 11/4/2024 that indicated the resident is on enhanced barrier precautions related to the presence of a gastrostomy tube (a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine). Record review revealed a care plan with a revision date of 12/4/2024 that revealed a care focus area for an indwelling foley catheter (a device that drains urine from your urinary bladder into a collection bag outside of your body when you can't urinate on your own). During a surveyor observation on 12/4/2024 at 10:02 AM, Nursing Assistant (NA), Staff C, was observed providing morning hygiene to the resident in his/her room, without wearing a gown. Further observation revealed signage posted at the resident's door which indicated to wear a gown and gloves during high contact care activities. During a surveyor interview and observation of Staff C, on 12/4/2024 at 10:05 AM, with Registered Nurse, Staff B, he acknowledged that the resident was on EBP related to his/her indwelling foley catheter and gastrostomy tube and then instructed Staff C that she is required to wear a gown and gloves while performing care. Staff C, then exited the resident's room and placed a gown on. Additional surveyor observation on 12/4/2024 at 12:50 PM, of Staff C and Staff B, they were observed providing hygiene care, including changing the bed linens for Resident ID #1. Further observation revealed that Staff C was not wearing a gown. Immediately following the above observation Staff B acknowledged that Staff C was not wearing a gown while providing care to and changing the bed linens for Resident ID #1. During a surveyor interview on 12/4/2024 at 1:24 PM with the Director of Nursing Services (DNS), she acknowledged that the resident was on EBP, and it would be her expectation that staff would wear the appropriate PPE as required per the facility policy. B. Record review of a physician's order dated 2/19/2024 states, Change the tube feeding syringe every night shift . Additional record review revealed that the above order was discontinued when the resident was admitted to the hospital on [DATE]. During a surveyor observation on 12/4/2024 at 10:30 AM, revealed an undated gastrostomy tube syringe on the resident's side table. Further observation revealed the syringe had an accumulation of dry, crusted white and red debris covering the inside surface area of the syringe. During a surveyor interview on 12/4/2024 at 10:35 AM, with Staff B, he acknowledged that the syringe was not dated and was unsure when it was last replaced. Additionally, he indicated that he had used the syringe that morning to administer the resident his/her medications. Record review of the November 2024 Medication Administration Record revealed the last time the facility staff had signed off that the syringe was replaced was on 11/23/2024, approximately 10 days prior to the above surveyor observation. During a surveyor interview on 12/4/2024 at approximately 1:30 PM with DNS, she revealed that she would have expected the syringe to be changed every 24 hours. C. Record review reveals that the resident receives treatments administered via a nebulizer machine. During a surveyor observation on 12/4/2024 at 10:30 AM, the resident's mask for his/her nebulizer machine treatments was located on the floor. Further observation revealed the tubing connected to the mask was dated, 11/20/2024, indicating the mask had not been changed in approximately 13 days. During a surveyor interview and observation on 12/4/2024 at 10:35 AM, with Staff B, he acknowledged that the nebulizer mask was on the floor in the resident's room and was dated 11/20/2024. Additionally, he acknowledged that the mask should not be on the floor and it should have been placed in a bag on the resident's side table. He further revealed that the mask and tubing should be changed once a week. During a surveyor interview on 12/4/2024 at approximately 1:30 PM with the DNS, she acknowledged that the resident's nebulizer mask should not be on the floor and would have expected the tubing and mask to be changed every 7 days.

Oct 2024 2 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 F0760 (Tag F0760)

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 are free fr...

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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 are free from significant medication errors for 1 of 1 resident reviewed who was administered antipsychotic medication (Clozaril) which was intended for another resident (Resident ID #2), Resident ID #1. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 10/5/2024 indicated that Resident ID #1 was transferred to an acute care hospital due a change in his/her mental status related to a potential medication error. Review of the manufacturer's guidance, last revised September 2024, revealed that Clozaril (clozapine) is an antipsychotic medication used to treat severe psychotic disorders. The starting dose is 12.5 milligrams (mg) and the peak (when the medication reaches the highest concentration in a person's blood) time can occur between 1 - 6 hours after administration. Warnings, precautions, and adverse reactions include, but are not limited to the following: - Hypersalivation (too much saliva or difficulty with properly clearing the saliva a person produces). - Severe neutropenia (low white blood cells which can lead to serious or fatal infections). For this reason, Clozaril is only available through a restricted risk evaluation program. - low blood pressure - low heart rate - syncope (fainting) - myocarditis (inflammation of the heart muscle) - cardiomyopathy (disorder affecting the heart muscle) - QT prolongation (an irregular heart rhythm or a change in how the heart's bottom chambers send signals, resulting in a longer time for the heart to recharge between beats). According to the National Library of Medicine's online article, last updated 12/26/2022 titled, Long QT Syndrome, a QTc greater than 500 is associated with an increased risk of torsade de pointes (a specific type of abnormal heart rhythm that can lead to sudden cardiac death). Review of the facility's medication administration policy and procedure dated June 2015 revealed the following procedural steps in part: - Verify the medication order on the Medication Administration Record (MAR) and check against the physician's order. - Identify the resident. - Avoid distractions and interruptions when preparing and administering medications to reduce the risk of medication errors. - Only prepare medication for one resident at a time. Record review revealed that Resident ID #1 was admitted to the facility in July of 2019 with diagnoses including, but not limited to, cirrhosis (liver disease) and alcoholic cardiomyopathy (a type of heart disease caused by long-term alcohol consumption that weakens the heart muscle and impairs its ability to pump blood). Review of a Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 7 out of 15, indicating severely impaired cognition. Record review of a progress note authored by Licensed Practical Nurse (LPN), Staff A, dated 10/5/2024 created at 6:01 PM, indicates that the nurse suspected a possible medication error after the resident was noted to be difficult to arouse after s/he was administered his/her medications. Additionally, the note indicates that the physician was notified and gave an order for the resident to be transferred to the hospital. During surveyor interviews on 10/7/2024 at 12:20 PM and 12:40 PM, with Staff A, she stated the following: - She was assigned to care for and administer medications to Resident ID #s 1 and 2 on 10/5/2024 during the 7:00 AM - 3:00 PM shift. - At some time between 8:00AM - 9:00 AM, she prepared medications for both Resident ID #1 and Resident ID #2 at the same time, while they were out in the corridor near her medication cart and was interrupted by another resident who was yelling in the background. - Resident ID #1's medication was in a medication cup on top of the medication cart along with a medication cup containing Clozaril 125 mg for Resident ID #2. - Staff A stated that she administered Resident ID #1's scheduled medications, which included, but was not limited to, lorazepam 0.5 mg (antianxiety) and Lexapro 10 mg (antidepressant). - Staff A believes that during the interruption, she may have administered Clozaril to Resident ID #1, which was intended for Resident ID #2, because the cup containing the Clozaril was no longer there. - Staff A checked on Resident ID #1 several times and obtained his/her vital signs several times. - Staff A placed a call to the on-call provider line immediately at the time of suspecting she administered the Clozaril to Resident ID #1. She waited on hold for an hour, continued her medication pass then placed another call when Resident ID #1 was difficult to arouse. - Staff A received a physician's order to send the resident to the hospital via Emergency Medical Services (EMS). Additional record review for Resident ID #1 failed to reveal evidence of a physician's order for Clozaril 125 mg. Record review for Resident ID #2 revealed a physician's order dated 5/29/2024 for Clozaril 100 mg tablet to be administered along with a 25 mg tablet to total 125 mg twice daily at 8:00 AM and 8:00 PM. Record review of the EMS patient care report document dated 10/5/2024 revealed that dispatch was notified at 11:10 AM and the EMS Unit arrived at the nursing facility at 11:15 AM for a report of Resident ID #1 being administered the wrong medication. S/he was noted to be in his/her bed, unresponsive, alert to pain only. Additionally, the resident required oxygen via a non-rebreather mask (an oxygen mask that delivers high concentrations of oxygen when a person needs oxygen quickly in emergencies) because his/her blood oxygen level was found to be 85% on room air (normal blood oxygen level is greater than 92% on room air). Additionally, his/her airway required suctioning (mechanical removal) to clear his/her airway. His/her respirations (breathing rate) were noted to be 11 (normal range is 12 - 20) and s/he was transported to the hospital. Review of the hospital document dated 10/5/2024 revealed Resident ID #1 presented to the Emergency Department (ED) for an accidental Clozaril overdose. Additionally, s/he was noted to be minimally arousable, was unable to articulate speech and was making gurgling sounds. The document further indicates that s/he was transferred to the Critical Care Unit where s/he required intubation (a medical procedure when a breathing tube is inserted through the mouth or nose into the windpipe allowing air to get into the lungs. The tube connects to a machine for automated air delivery or a bag for manual air delivery) to protect his/her airway. Furthermore, s/he was noted to have a QTc of 520 (normal range is 360 to 460) which required a consult with poison control who recommended s/he be treated with a higher dose of intravenous (IV) Magnesium (magnesium is an electrolyte used to treat abnormal heart rhythms. IV Magnesium administration requires strict medical monitoring in the hospital setting). S/he was admitted for further management. The treatment plan included but is not limited to the following: acute toxic encephalopathy (altered mental status) secondary to Clozaril overdose, toxicity secondary to accidental overdose, and acute respiratory failure secondary to inability to protect airway. During a surveyor interview on 10/8/2024 at 10:59 AM, with Resident ID #1's Nurse Practitioner (NP) along with her Clinical Manager via the telephone, she reviewed the electronic documentation for weekend on-call provider log. The NP stated that on 10/5/2024 at 10:48 AM, Staff A left a voicemail reporting a medication error for Resident ID #1; s/he was very sleepy after s/he was administered Clozapine 125 mg, which s/he does not receive. Furthermore, the NP indicated that the resident's physician was notified and gave an order for the resident to be transferred to the hospital. During a surveyor interview on 10/8/2024 at 1:21 PM, with the Director of Nursing Services (DNS), she acknowledged that she would have expected Staff A to administer and prepare medications for one resident at a time, per the facility's policy. Additionally, she was unable to provide evidence that Resident ID #1 was kept free from significant medication error. As a result of this survey, it has been determined that Resident ID #1 was placed at risk for serious harm or injury due to Staff A's failure to administer medication according to the facility's policy, when she prepared and administered medications for both Resident ID #'s 1 and 2. Resident ID #1 was administered medication intended for Resident ID #2 which resulted in Resident ID #1 exhibiting adverse effects of Clozaril which required transfer to the hospital's Critical Care Unit.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of qu...

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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 meet professional standards of quality relative to evaluating a resident after a suspected medication error occurred 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 10/5/2024 indicated that Resident ID #1 was transferred to an acute care hospital because s/he potentially received antipsychotic medication intended for another resident and was noted with a change in his/her mental status. Review of a facility policy and procedure dated April 2015 titled, MEDICATION ERROR REPORTING states in part, .A Medication error is any preventable event that may cause or lead to inappropriate medication use, which the medication is in the control of the health care professional . - A licensed nurse makes an immediate evaluation of the resident in relation to the nature of the error . - Follow-up notes are written related to event base on evaluation per facility policy . Record review revealed that Resident ID #1 was admitted to the facility in July of 2019 with diagnoses including, but not limited to, cirrhosis (liver disease) and alcoholic cardiomyopathy (a type of heart disease caused by long-term alcohol consumption that weakens the heart muscle and impairs its ability to pump blood). Review of a Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 7 out of 15, indicating severely impaired cognition. Record review of a progress note authored by Licensed Practical Nurse (LPN), Staff A, dated 10/5/2024 created at 6:01 PM, indicates that the nurse suspected a possible medication error after the resident was noted to be difficult to arouse after s/he was administered his/her medication. Additionally, the note indicates that the physician was notified and gave an order for the resident to be transferred to the hospital. During surveyor interviews on 10/7/2024 at 12:20 PM and 12:40 PM, with Staff A, she stated the following: - She was assigned to care for and administer medications to Resident ID #s 1 and 2 on 10/5/2024 during the 7:00 AM - 3:00 PM shift. - At some time between 8:00AM - 9:00 AM, she prepared medications for both Resident ID #1 and Resident ID #2 at the same time, while they were out in the corridor near her medication cart and another resident was yelling in the background. - Resident ID #1's medication was in a medication cup on top of the medication cart along with a medication cup containing Clozaril 125 milligram (mg) for Resident ID #2. - Staff A stated that she administered Resident ID #1's scheduled medications, which included, but was not limited to, lorazepam 0.5 mg (antianxiety) and Lexapro 10 mg (antidepressant). - Staff A believes that during the interruption, she may have administered Clozaril to Resident ID #1, which was intended for Resident ID #2, because the cup containing the Clozaril was no longer there. - Staff A checked on Resident ID #1 several times and obtained his/her vital signs several times. - Staff A placed a call to the on-call provider line immediately at the time of suspecting she administered the Clozaril to Resident ID #1. She waited on hold for an hour, continued her medication pass, then placed another call when Resident ID #1 was difficult to arouse. - Staff A received a physician's order to send the resident to the hospital via Emergency Medical Services (EMS). Further record review failed to reveal evidence that Resident ID #1 was evaluated immediately after the medication error was suspected or documentation that additional follow up evaluations of the resident occurred. During a surveyor interview on 10/8/2024 at 10:59 AM, with Resident ID #1's Nurse Practitioner (NP) along with her Clinical Manager via the telephone, she reviewed the electronic documentation of the weekend on-call provider log. The NP stated that on 10/5/2024 at 10:48AM, Staff A left a voicemail reporting a medication error for Resident ID #1 was very sleepy after s/he was administered Clozapine 125 mg intended for another resident. Furthermore, the NP indicated that the resident's physician was notified and gave an order for the resident to be transferred to the hospital. The NP acknowledged that she would have expected that Staff A would have contacted the on-call provider immediately after the mediation error was suspected. During a surveyor interview on 10/8/2024 at 1:21 PM, with the Director of Nursing Services (DNS), she was unable to provide evidence that Staff A evaluated Resident ID #1 immediately after the medication error was suspected, or documentation that additional follow up evaluations of the resident occurred.

Oct 2024 2 deficiencies 2 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

Based on record review and staff interview, it has been determined that the facility failed to keep a resident free from sexual abuse for 1 of 5 residents reviewed, Resident ID #1. Findings are as fol...

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Based on record review and staff interview, it has been determined that the facility failed to keep a resident free from sexual abuse for 1 of 5 residents reviewed, Resident ID #1. Findings are as follows: Review of a facility policy titled, Abuse Prohibition Policy dated September 2020, states in part, .It will be the facility's responsibility to identify, correct and intervene in situations where abuse, mistreatment, neglect, exploitation and/or misappropriation of resident property occur .sexual abuse includes, but is not limited to, sexual harassment, sexual coercion or sexual assault. Sexual abuse is non-consensual sexual contact of any type with a resident . Review of a facility reported incident submitted to the Rhode Island Department of Health on 9/30/2024 revealed that Resident ID #s 1 and 2 reported to a supervisor on 9/26/2024 that they were engaging in a consensual sexual relationship. On the morning of 9/30/2024, Resident ID #1 reported to the Director of Social Services that s/he had sex with Resident ID #2 three times since 9/27/2024 and all of these instances were without his/her consent. Record review revealed that Resident ID #1 (the alleged victim) was admitted to the facility in September 2022 with diagnoses including, but not limited to, paranoid personality disorder and anxiety. Review of a Minimum Data Set (MDS) Assessment for Resident ID #1 dated 8/26/2024 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating intact cognition. Review of a progress note dated 9/27/2024, authored by the Director of Social Services, revealed that he met with Resident ID #1 relative to him/her being involved in a physical relationship with Resident ID #2. Resident ID #1 indicated that s/he felt safe and is happy with the relationship. Additionally, the progress note indicated that the Director of Social Services informed Resident ID #1 that if s/he ever felt unsafe or uncomfortable that staff are available to support him/her. Review of a progress note dated 9/30/2024, authored by the Director of Social Services, revealed that Resident ID #1 reported to him that Resident ID #2 had gotten into bed with him/her although s/he told him/her not to. Additionally, the progress note revealed that Resident ID #1 reported sexual activity occurred on Friday (9/27/2024), Saturday (9/28/2024), and Sunday (9/29/2024) without his/her consent. Further record review revealed that Resident ID #1 was transferred to an acute care hospital for an evaluation related to genital pain. Review of emergency room documentation dated 9/30/2024 revealed Resident ID #1 was being treated for a potential sexual assault. Additionally, it revealed that Resident ID #1 reported being penetrated with an object but was unable to identify what the object was. Additional review revealed that Resident ID #1 was forced to wear outfits and role play with Resident ID #2. The document further revealed that Resident ID #1 was experiencing dysuria (painful or difficulty with urination), pelvic pain and pain to his/her genital area. Lastly the documentation revealed that, while in the Emergency Room, Resident ID #1 was noted to be anxious and tremulous. Review of a facility provided statement authored by a laundry aide, Staff A revealed that on Sunday 9/29/2024 at around 10:30 AM Resident ID #1 was crying and told her that Resident ID #2 was trying to get into bed with him/her and s/he felt like Resident ID #2 was moving too fast. The statement further revealed that Resident ID #1 felt uncomfortable around Resident ID #2 because s/he was moving so fast and Resident ID #1 showed Staff A hickeys on his/her neck. The statement revealed that Staff A encouraged Resident ID #1 to speak to a Nursing Assistant and talk to the Director of Social Services on Monday. During a surveyor interview on 10/1/2024 at 12:11 PM with Staff A, she acknowledged that Resident ID #1 did tell her that s/he was uncomfortable with Resident ID #2 on Sunday 9/29/2024. Staff A acknowledged that she told Resident ID #1 to talk to the Director of Social Services the following day. Additionally, she revealed that she did not identify Resident ID #1's concerns as potential abuse at the time. Review of a facility provided statement authored by Nursing Assistant, Staff B revealed that on Sunday 9/29/2024 Resident ID #1 told her that Resident ID #2 was moving too fast and s/he wanted him/her to slow down. It further revealed that Resident ID #1 was having mixed emotions and did not know what to do. The statement revealed that Resident ID #1 wanted to tell Resident ID #2 but s/he was afraid and showed Staff B hickeys on his/her neck. During a surveyor interview via telephone on 10/1/2024 at 1:04 PM with Staff B, she revealed that Resident ID #1 told her that s/he felt that Resident ID #2 was moving too fast but s/he was afraid to talk to him/her about it. Staff B acknowledged that she encouraged Resident ID #1 to talk to the Director of Social Services the following day. Staff B revealed that she did tell Licensed Practical Nurse (LPN), Staff C about the concerns Resident ID #1 had with Resident ID #2. During a surveyor interview on 10/1/2024 at 1:45 PM with Staff C, she revealed that she did hear that Resident ID #1 felt that Resident ID #2 was moving too fast on 9/29/2024. Additionally, she acknowledged that she did not talk to Resident ID #1 and did not investigate his/her concerns. Resident ID #1 was unavailable for a surveyor interview due to being discharged to the hospital. Record review revealed that Resident ID #2 (the alleged perpetrator) was admitted to the facility in July of 2024 with a diagnosis including, but not limited to, bipolar disorder. Review of an MDS Assessment for Resident ID #2 dated 7/31/2024 revealed a BIMS score of 13 out of 15 indicating intact cognition. Resident ID #2 was unavailable for a surveyor interview due to the resident requesting to be discharged home on 9/30/2024. Record review failed to reveal evidence that the facility staff initiated any interventions to ensure Resident ID #1's safety from Sunday 9/29/2024 at approximately 10:00 AM, when staff were made aware by Resident ID #1 that s/he was uncomfortable with Resident ID #2, as s/he was moving too fast for him/her within their relationship, until Monday 9/30/2024 when Resident ID #1 alleged that s/he was sexually assaulted. Resident ID #1 alleged that s/he was sexually assaulted on Sunday night 9/29/2024 after s/he expressed concerns to staff. During a surveyor interview on 10/1/2024 at approximately 12:05 PM with the Administrator he acknowledged that Resident ID #1 communicated concerns to the facility staff but that they did not identify it as abuse. Additionally, he was unable to provide evidence that the facility kept Resident ID #1 free from abuse on the evening of 9/29/2024. Cross reference F610

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

Investigate Abuse (Tag F0610)

A resident was harmed · This affected 1 resident

Based on record review and staff interview it has been determined that the facility failed to ensure that allegations made by residents are recognized as possible abuse by staff, all allegations are i...

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Based on record review and staff interview it has been determined that the facility failed to ensure that allegations made by residents are recognized as possible abuse by staff, all allegations are investigated, and that residents are kept free from experiencing further abuse during investigations for 1 of 1 Resident reviewed who expressed concerns to staff members regarding a consensual sexual relationship with another resident, Resident ID #1 (the alleged victim). Findings are as follows: Review of a facility policy titled, Abuse Prohibition Policy dated September 2020, states in part, .each resident has the right to be free from abuse .Procedure .identifying events, occurrences, patterns and trends of potential abuse for residents. Performing internal facility investigations of alleged violations and identification of staff members responsible for investigating incidents and reporting of the same to proper authorities. Protecting residents from harm during an investigation of alleged abuse . Review of a facility in-service on abuse dated 3/6/2023 states in part, .Identification of abuse .Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place or feelings of guilt or shame . Review of a facility reported incident submitted to the Rhode Island Department of Health on 9/30/2024 revealed that Resident ID #s 1 and 2 reported to a supervisor on 9/26/2024 that they were engaging in a consensual sexual relationship. On the morning of 9/30/2024, Resident ID #1 reported to the Director of Social Services that s/he had sex with Resident ID #2 (the alleged perpetrator) three times since 9/27/2024 and all of these instances were without his/her consent. Record review revealed that Resident ID #1 was admitted to the facility in September 2022 with diagnoses including, but not limited to, paranoid personality disorder and anxiety. Review of a Minimum Data Set (MDS) Assessment for Resident ID #1 dated 8/26/2024 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating intact cognition. Review of a facility provided statement authored by a laundry aide, Staff A revealed that on Sunday 9/29/2024 at around 10:30 AM Resident ID #1 was crying and told her that Resident ID #2 was trying to get into bed with him/her and s/he felt like Resident ID #2 was moving too fast. The statement further revealed that Resident ID #1 felt uncomfortable around Resident ID #2 because s/he was moving so fast. The statement revealed that Staff A encouraged Resident ID #1 to speak to a Nursing Assistant and talk to the Director of Social Services on Monday. During a surveyor interview on 10/1/2024 at 12:11 PM with Staff A, she acknowledged that Resident ID #1 did tell her that s/he was uncomfortable with Resident ID #2 on Sunday 9/29/2024. Staff A acknowledged that she told Resident ID #1 to talk to the Director of Social Services the following day. Additionally, she revealed that she did not identify Resident ID #1's concerns as potential abuse at the time nor did she investigate any further. Review of a facility provided statement authored by Nursing Assistant, Staff B revealed that on Sunday 9/29/2024 Resident ID #1 told her that Resident ID #2 was moving too fast and s/he wanted him/her to slow down. It further revealed that Resident ID #1 was having mixed emotions and did not know what to do. The statement revealed that Resident ID #1 wanted to tell Resident ID #2 but s/he was afraid. During a surveyor interview via telephone on 10/1/2024 at 1:04 PM with Nursing Assistant (NA), Staff B, she revealed that Resident ID #1 told her that s/he felt that Resident ID #2 was moving to fast but s/he was afraid to talk to him/her about it. Staff B acknowledged that she encouraged Resident ID #1 to talk to the Director of Social Services the following day. Staff B revealed that she told Licensed Practical Nurse (LPN), Staff C about the concerns Resident ID #1 had with Resident ID #2. During a surveyor interview on 10/1/2024 at 1:45 PM with LPN, Staff C she revealed that she was made aware of Resident ID #1 telling Staff B about his/her concerns about Resident ID #2 moving too fast. Additionally, she acknowledged that she did not go talk to Resident ID #1 and did not further investigate any concerns. Review of emergency room documentation dated 9/30/2024 revealed Resident ID #1 was being treated for potential sexual assault. Additionally, it revealed that Resident ID #1 reported being penetrated with an object but was unable to identify what the object was. Further review revealed that Resident ID #1 was experiencing dysuria (pain or difficulty with urination), pelvic pain and pain to his/her genital area. While in the emergency room Resident ID #1 was noted to be anxious and tremulous. Resident ID #1 was unavailable for a surveyor interview due to being discharged to the hospital. Record review revealed that Resident ID #2 was admitted to the facility in July of 2024 with a diagnosis including, but not limited to, bipolar disorder. Review of an MDS Assessment for Resident ID #2 dated 7/31/2024 revealed a BIMS score of 13 out of 15 indicating intact cognition. Resident ID #2 was unavailable for a surveyor interview as the resident requested to be discharged home on 9/30/2024. During a surveyor interview on 10/1/2024 at approximately 12:05 PM with the Administrator he acknowledged that Resident ID #1 communicated concerns to the facility staff but that they did not identify it as potential abuse. Additionally, he was unable to provide evidence that the facility prevented further potential abuse from occurring to Resident ID #1 while an investigation was being conducted or that the facility initiated an investigation to determine if Resident ID #1 had been abused. Cross reference F600

Sept 2024 5 deficiencies

CONCERN (D)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents who are fed by a feeding tube receive the appropriate treatm...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents who are fed by a feeding tube receive the appropriate treatment and services to prevent complications for 1 of 2 residents reviewed relative to a gastrostomy tube (G-tube, which is a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine), Resident ID #76. Findings are as follows: Review of the policy titled Enteral Feeding dated April 2015 states in part, PROCEDURE .Elevate head of bed 30-45 degrees . Record review revealed the resident was re-admitted to the facility in February of 2024 with diagnoses including, but not limited to, dysphagia (difficulty swallowing) and Alzheimer's disease. Record review revealed a physician's order dated 2/17/2024 to elevate the resident 30-45 degrees at all times during feeding and for one hour after gravity feeds or resident must be elevated at all times with continuous feeding. Further record review revealed a physician's order dated 8/1/2024 to receive Nepro Carb Steady (a therapeutic nutrition specifically designed to help meet the nutritional needs of people with chronic kidney disease) 237 milliliters via g-tube four times a day at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM. During a continuous surveyor observation on 9/11/2024 from 8:57 AM through 9:17 AM, it was revealed that the resident's head of the bed was not elevated to a position of at least 30 degrees for one hour after receiving his/her therapeutic nutrition. During a surveyor interview on 9/11/2024 at 9:17 AM with Licensed Practical Nurse, Staff H, she revealed that the resident completed his/her therapeutic nutrition at approximately 8:30 AM and acknowledged that the resident's head of the bed should have been elevated at least 30 degrees, as ordered. During a surveyor interview on 9/11/2024 at 2:38 PM with the Director of Nursing Services, she acknowledged that the resident's head of the bed should have been elevated to 30-45 degrees for 1 hour after receiving his/her therapeutic nutrition.

CONCERN (E)

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 and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice re...

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Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to following physicians' orders for 4 of 4 residents reviewed for intake and output (I&O), Resident ID #s 26, 30, 61, and 104. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing page 314, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Review of the facility's policy and procedure for INTAKE AND OUTPUT MONITORING dated April, 2015 states in part, .Intake and Output will be monitored, as indicated by the resident's hydration status, risk for dehydration, and/or per physician's order .Intake and Output is documented for each shift, beginning with the 11 to 7 shift .Intake and Output is totaled daily by the 3 to 11 shift nurse and the 24 hour totals are transcribed to the Medication Administration Record . 1. Record review revealed Resident ID #26 was re-admitted to the facility in June of 2024 with diagnoses including, but not limited to, retention of urine and uropathy (a urinary tract blockage). Additional record review reveals the resident has a suprapubic catheter (a hollow flexible tube that is used to drain urine from the bladder). Further record review revealed a physician's order dated 6/13/2024 to document the resident's I&O on the paper flow sheet every shift for suprapubic catheter placement. Record review of the paper I&O flow sheets from 9/1/2024 through 9/10/2024. failed to reveal evidence that the resident's I&Os were documented every shift as ordered for 27 of 30 opportunities, indicating that the facility was not aware of the resident's I&Os. During a surveyor interview on 9/12/2024 at 1:54 PM with the Director of Nursing Services (DNS), she was unable to provide evidence that the physician's order to document the resident's I&O every shift, for suprapubic catheter placement, on the paper flow sheets were followed. 2. Record review revealed Resident ID #30 was re-admitted to the facility in September of 2023 with diagnoses including, but not limited to, chronic kidney disease, uropathy, and heart failure. Additional record review reveals the resident has a suprapubic catheter. Record review revealed a physician's order dated 3/20/2024 to document the resident's I&O on the paper flow sheet every shift. Record review of the paper I&O flow sheets from 9/1/2024 through 9/10/2024, failed to reveal evidence that the resident's I&Os were documented every shift, as ordered, for 26 of 30 opportunities. During a surveyor interview on 9/11/2024 at 8:50 AM with Registered Nurse, Staff B, she was unable to provide evidence that the I&Os were documented. Additionally, Staff B acknowledged that the order for I&Os was not followed. During a surveyor interview on 9/11/2024 at approximately 1:30 PM with the DNS, she revealed that she would expect staff to follow the physician's orders. 3. Record review revealed Resident ID #61 was re-admitted to the facility in May of 2024 with diagnoses including, but not limited to, high blood pressure, and prostatic hyperplasia (a condition in which the flow of urine is blocked due to the enlargement of prostate gland). Additional record review reveals the resident has a suprapubic catheter. Record review revealed the resident has a physician's order dated 3/20/2024 to document the resident's I&Os on the paper flow sheet every shift. Record review of the paper I&O flow sheets from 9/1/2024 through 9/10/2024, failed to reveal evidence that the resident's I&Os were documented every shift, as ordered, for 30 out of 30 opportunities. During a surveyor interview on 9/12/2024 at 1:50 PM with the DNS, she revealed that she would expect staff to follow the physician's orders. 4. Record review revealed Resident ID #104 was admitted to the facility in July of 2024 with diagnoses including, but not limited to, acute kidney injury and chronic kidney disease. Record review revealed the resident has a physician's order dated 8/14/2024 to monitor I&Os every shift. Review of the September 2024 Treatment Administration Record revealed that staff documented an amount of fluid but failed to indicate if the amounts documented were the resident's intake or output. Furthermore, staff on the 11:00 PM-7:00 AM shift failed to document any amount of I&Os on the TAR for 9 out of 10 opportunities. Record review of the paper I&O flow sheets from 9/1/2024 through 9/10/2024, failed to reveal evidence that the resident's I&Os were documented every shift, as ordered, for 30 of 30 opportunities. During a surveyor interview on 9/11/2024 at approximately 2:00 PM with LPN, Staff C, she was unable to provide evidence that the I&Os were documented every shift. Staff C acknowledged that the order for I&Os was not followed. During a surveyor interview on 9/12/2024 at approximately 11:30 AM, with the DNS, she revealed that she would expect staff to follow the physician's orders.

CONCERN (E)

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

Deficiency F0692 (Tag F0692)

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 residents maintain acceptable parameters of nutritional status, such a...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight, for 3 of 6 residents reviewed for significant weight loss and/or gain, Resident ID #s 76, 96, and 104. Findings are as follows: Record review of the policy titled, Weights, last revised in August 2015, states in part, The following residents/patients are weighed weekly X4 [for four weeks] .Residents/patients with an MD [doctor] order for weekly weights .The same scale should be used for each weighing of a particular resident/patient to ensure consistency and more accurate weights .All weight loss/gain of 3 pounds or more on a resident weighing 100 pounds or less and weight loss/gain of 5 pounds or more on a resident weighing 100 pounds or more requires a reweigh for verification. A reweigh is done on the same scale with a licensed nurse present. Weights are documented in the resident's/patient's medical record and/or weight book. If a significant weight loss/gain is identified (> [greater than] 5% in 30 days or >10% in 6 months), the IDT [interdisciplinary team], Dietitian, Physician and Family are notified . 1. Review of Resident ID #76's record revealed s/he was admitted to the facility in May of 2021 with diagnoses including, but not limited to, Alzheimer's disease, adult failure to thrive, dysphagia (difficulty swallowing), and gastrostomy status (g-tube, an opening from the abdomen into the stomach that allows a feeding tube to deliver food, fluids and medications directly into the stomach). Record review revealed a physician's order to obtain weekly weights. Record review revealed the following documented weights: - 8/6/2024 90.5 pounds (lbs.) - 8/13/2024 90.8 lbs. - 9/4/2024 83.0 lbs. - 9/10/2024 80.0 lbs. Record review of the August 2024 Treatment Administration Record (TAR) revealed that the order for weekly weights was signed as completed on 8/20/2024 and on 8/27/2024. Additional record review failed to reveal evidence of documented weights for 8/20/2024 and 8/27/2024. Record review revealed the resident lost 7.8 pounds from 8/13/2024 to 9/4/2024, which is a significant weight loss of 8.59% in less than one month. A subsequent weight taken on 9/10/2024 revealed the resident lost an additional 3 pounds, resulting in a severe weight loss of 11.89% in a one-month period. During a surveyor interview with Licensed Practical Nurse, Staff D, on 9/12/2024 at 11:12 AM, she revealed that nurses document weights in the record and note if there are any significant changes in weight. She indicated she would have expected the nursing assistant to reweigh the resident the same day if there was a discrepancy, to verify the accuracy of the weight. If a discrepancy is identified on the reweigh, she would then contact the Registered Dietitian (RD) and the resident's provider. Additionally, she indicated that she was not aware of Resident ID #76's weight loss on 9/4/2024 or 9/10/2024 and that she would have contacted the RD and provider if she was had been aware. During a surveyor observation in the presence of Staff D on 9/12/2024 at 11:29 AM, Resident ID #76's weight was obtained via mechanical lift after the surveyor brought this concern to the facility's attention. The resident weighed 83.6 lbs., which verified a significant weight loss of 7.9% in approximately one month. During a surveyor interview with the RD on 9/12/2024 at 11:38 AM, she revealed she was not made aware of the resident's significant weight loss on 9/4/2024 or 9/10/2024 until it was brought to her attention by Staff D shortly before this interview. During a surveyor interview with the Physician, Staff E, on 9/12/2024 at 12:02 PM, he revealed that he last saw Resident ID #76 on 9/1/2024 or 9/2/2024 and that he and his Nurse Practitioner were not notified by the facility of the resident's weight loss on 9/4/2024 or 9/10/2024 until it was brought to his attention shortly before this interview. During surveyor interviews with the Director of Nursing Services (DNS) on 9/12/2024 at 1:04 PM and at 1:50 PM, she was unable to provide evidence weekly weights were obtained, as ordered, on 8/20/20244 and 8/27/2024. She also revealed that following a weight change of 3 pounds or more for a resident who is under 100 pounds, she would expect that a reweigh would be completed to verify the weight. Additionally, she revealed that she would expect that the RD and the Physician to have been notified following the resident's significant weight loss on 9/4/2024 and 9/10/2024. 2. Record review revealed Resident ID #96 was admitted to the facility in October of 2023, with diagnoses including, but not limited to, post-traumatic stress disorder, bipolar disorder, and anxiety disorder. Record review of a document titled Nutrition Evaluation dated 7/8/2024, revealed the resident's weight was .160.4 [lbs.] up 18.9% in the past six months. This was not planned. [Weight] gain was anticipated with previous supplement, but this amount of weight gain was not anticipated .[weight] loss is anticipated. Review of the Weight Summary revealed on 7/16/2024 the resident weighed 157.4 lbs. and on 8/5/2024 s/he weighed 174 lbs., indicating a 16.6 lb. weight gain, a significant gain of 10.55% in less than 30 days. Additionally, the resident was weighed on 9/1/2024 and the weight obtained was also 174 lbs. Record review failed to reveal evidence that a reweigh was obtained on 8/5/2024 per the facility policy. During a surveyor interview on 9/12/2024 at 9:52 AM with the Nurse, Staff F, she revealed that weights are done by nursing assistants and if a weight reveals an increase or decrease of 3 lbs., a reweigh is indicated, and the changes in weights are documented and reported to the physician or nurse practitioner. Staff F, was unable to provide evidence that the above-mentioned weights obtained were documented and reported, per policy. During a surveyor interview on 9/12/2024 at 10:03 AM with the Nurse Practitioner, Staff G, she revealed she was not aware of the resident's weight gain. During a surveyor interview on 9/12/2024 at 11:41 AM with the RD, she revealed that she was not aware of Resident ID #96's significant weight gain. 3. Record review revealed Resident ID #104 was admitted to the facility in July of 2024 with diagnoses including, but not limited to, diabetes mellitus, acute kidney injury, and chronic kidney disease. Review of the Weight Summary revealed the resident's weight was 248.3 lbs. on 8/6/2024 and 231.2 lbs. on 9/1/2024, indicating a 17.1 lb. weight loss in less than a month. Record review failed to reveal evidence that the reweigh was obtained, per the facility policy, on 9/1/2024. During a surveyor interview on 9/12/2024 at 11:46 AM with the LPN, Staff C, she was unable provide evidence that the reweight was obtained on or after 9/1/2024. During a surveyor interview on 9/12/2024 at 12:21 PM with the DNS, she revealed that the reweigh should obtained within the next day. She acknowledged the weight was not obtained per the facility's policy. During a surveyor interview on 9/12/2024 at 12:51 PM with the RD, she revealed she would expect staff to reweigh the resident after a significant weight change.

CONCERN (E)

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

Deficiency F0699 (Tag F0699)

Could have caused harm · This affected multiple residents

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care, in accordance with professional standards of practice and accounting for residents' experiences and preferences, in order to eliminate or mitigate triggers that may cause re-traumatization for 1 of 1 resident reviewed, relative to a resident with history of post traumatic stress disorder (PTSD), Resident ID #96. Findings are as follows: Record review revealed the resident was admitted to the facility in October of 2023, with diagnoses including, but not limited to, PTSD, bipolar disorder, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 out of 15, indicating intact cognition. Review of a document titled Social Service Trauma-Informed Care Screening Tool dated 10/3/2023, revealed a series of 7 questions designed to identify a resident with a history of trauma. Question number 2 asked if the resident had ever experienced any of the following: serious accident, sexual or physical assault, life threatening illness, natural disaster, or violent loss of a family member or close friend, and the resident answered yes. Further review of this document failed to identify precisely what type of trauma the resident had experienced, or resident preferences to be implemented, in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Record review on 9/9/2024 at approximately 1:00 PM, failed to reveal evidence that the facility completed an assessment or used a multifaceted approach to identify the resident's history of trauma as well as his/her preferences that include the triggers (defined as a psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening), that may be stressors for him/her. During surveyor interviews on 9/9/2024 at 1:20 PM, and 9/11/2024 at 9:08 AM, with the resident, s/he was noted to avoid making eye contact with the surveyor when speaking. Additionally, s/he indicated that s/he was willing to participate in a conversation regarding her care. During a surveyor interview on 9/9/2024 at 1:20 PM with the Medication Technician , Staff N, she revealed that she was unaware of the resident's history of trauma or his/her potential triggers. During a surveyor interview on 9/11/2024 at 11:53 AM with Licensed Practical Nurse (LPN), Staff A, she indicated that she was unaware of any triggers the resident may have. During a surveyor interview on 9/12/2024 at 9:52 AM with the LPN, Staff F, she indicated that she was unaware of the resident's history of trauma or his/her potential triggers. During a surveyor interview on 9/11/2024 at 12:05 PM with the Social Worker, Staff I, he was unable to provide evidence that a comprehensive assessment was completed to identify the nature of or the triggers for the resident's trauma, to eliminate or mitigate triggers that may cause re-traumatization to the resident. Record review of a document titled Optum Behavioral Health Advanced Practice Clinician [APC] Follow Up dated 8/5/2024 revealed a recommendation to obtain the resident's outpatient psychiatric records to confirm history or diagnoses and prior treatments. During an additional interview with Staff I on 9/12/2024 at 12:19 PM, he indicated that he was unaware of the recommendation from Optum Behavioral Health APC dated 8/5/2024 to obtain the resident's outpatient psychiatric records. During a surveyor interview on 9/12/2024 at 10:25 AM, with the Director of Nursing Services, she indicated that she would expect a completed Trauma-Informed Care Assessment that identifies the nature of the trauma for residents with a diagnosis of PTSD.

CONCERN (F)

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

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

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

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections by failing to implement appropriate precautions, documentation of follow-up activity in response and comply with state and local public health authority requirements for identification, reporting, and containing communicable diseases and outbreaks. Furthermore, the facility failed to don [put on] the required Personal Protective Equipment (PPE) prior to entering resident rooms that required precautions for 1 of 2 units reviewed. Findings are as follows: 1. Review of a facility policy titled, RI CORONAVIRUS (COVID-19) exposure states in part, This facility follows the professional standards and recommendations set forth by the Center of Disease Control [CDC], CMS [Centers for Medicare and Medicaid Services] and state health care agencies regarding coronavirus .The facility will actively screen all employees, vendors, and delivery personnel upon entrance to the facility during outbreak periods .The facility will monitor residents for COVID-19 symptoms daily and will increase monitoring to QS [every shift] on affected units during an outbreak .The facility will follow all CDC and State specific guidance for vaccinations and testing .All residents will be screened for COVID-19 symptoms daily . Upon surveyor entrance to the facility on 9/9/2024 at approximately 8:00 AM the survey team was informed by the Receptionist, Staff O, that the facility is experiencing a COVID-19 outbreak. The survey team was not screened for COVID-19 and was directed to the conference room. Surveyor observations between 9/9-9/11/2024 and record review, failed to reveal evidence that employees and/or visitors were screened for COVID-19 symptoms upon entering the building per the local public health authority recommendations. During a surveyor interview on 9/10/2024 at 9:15 AM with Nursing Assistant (NA), Staff K, NA Staff L, and the unit secretary, Staff M, they indicated they have not been screened for signs and symptoms of COVID-19 upon entering the building for the last several weeks. During a surveyor interview on 9/9/2024 at approximately 9:00 AM with the Director of Nursing Services (DNS), she revealed that during an outbreak, it is the facility's policy to follow the recommendations provided by the CDC and the local public health authority. She further revealed that the local public health authority was contacted via email on 9/1/2024 relative to the facility's COVID-19 outbreak. During a surveyor telephone interview on 9/10/2024 at approximately 10:29 AM with the local public health authority, they indicated the following recommendations were given to the facility in response to the facility's COVID-19 outbreak through email correspondence on 9/1/2024: - Screen visitors and employees for signs and symptoms of COVID-19 upon entering the building - All staff to wear a N95 in the resident care areas - COVID-19 testing two times a week for staff and residents - Monitor residents for signs and symptoms of COVID-19 Record review of an undated facility document titled, Residents revealed a list of 21 residents who tested positive for COVID-19 from 9/1/2024 through 9/8/2024. Record review failed to reveal evidence that the facility's staff were being tested for COVID-19 twice a week per the recommendations. Record review revealed Resident ID #71 tested positive for COVID-19 on 9/5/2024. A surveyor observation on 9/9/2024 at 11:29 AM, revealed that NA, Staff J, was wearing two surgical masks and not a N95 mask upon entering Resident ID #71's room. Further observation revealed Resident ID #71 had an isolation cart outside of the room with a droplet/contact precaution sign that states in part, Isolation Droplet/Contact .clean hands .gowns .N95 Respirator .Eye protection (goggles or face shield) .Gloves . During an interview following the above observation with Staff J, she acknowledged that Resident ID #71 was positive for COVID-19 and that there was a sign indicating the proper PPE use which includes a N95 mask. Staff J acknowledged that she was not wearing a N95 mask when she entered Resident ID #71's room. During a surveyor interview on 9/10/2024 at 12:27 PM with the Regional Director of Clinical Services in the presence of the Regional Director of Infection Control, the Infection Preventionist, and the DNS, she acknowledged that the facility was not following the facility policy, or the recommendations provided by the public health authority to screen visitors and employees for signs and symptoms of COVID-19. Additionally, she could not provide evidence that the staff were being tested for COVID-19 twice weekly. During a surveyor interview on 9/10/2024 at approximately 2:00 PM with the DNS, she was unable to provide evidence that the facility implemented appropriate precautions to prevent further transmission of the illness, as well as documentation of follow-up activity in response, and comply with state and local public health authority requirements for identification, reporting, and containing COVID-19. 2. Review of a facility policy titled, Enhanced Barrier Precautions Policy states in part, Enhanced barrier precautions (EBP) require the use of a gown and gloves for certain residents during specific high-contact resident care activities in which there is risk for transmission of multidrug-resistant organisms. High-contact resident care activities include bathing/showering, providing hygiene, dressing, transferring, linen changes . Record review revealed that Resident ID #104 was admitted to the facility in July of 2024 with diagnoses including but not limited to, diabetes, hyperlipidemia, and Methicillin-resistant Staphylococcus aureus (MRSA, a type of infection resistant to several antibiotics). Record review revealed the resident has a physician's order dated 8/14/2024, which states enhanced barrier precautions related to history of MRSA. During a surveyor observation on 9/11/2024 at approximately 9:05 AM, two nursing students, Students 1 and 2, were observed assisting Resident ID #104 change his/her hospital clothes and assist him/her to transfer to a wheelchair. The students then changed the residents' linens and brought the dirty linens outside of the room. During the above observation both students failed to wear a gown. Further surveyor observation of the signage posted on the resident's door revealed in part, Enhanced Barrier Precautions; Attention: Caregivers, staff and visitors .Wear gloves and a gown for the following High-Contact Resident Care Activities: Dressing Bathing/Showering Transferring Changing linens . During a surveyor interview on 9/11/2024 with Student 1 at 9:08 AM, and Student 2 at 9:14 AM, they both acknowledged that they failed to wear a gown. During a surveyor interview on 9/11/2024 at 12:27 PM with the Infection Preventionist in the presence of the DNS, she stated that she would expect for staff and visitors to follow infection control practices and wear all required PPE to enter rooms under isolation precautions.

Jul 2024 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

Quality of Care (Tag F0684)

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 a resident receives treatment and care in accordance with professional standards of practice...

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Based on record review, and staff interview, it has been determined that the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed for the use of Humira (a medication used to treat rheumatoid arthritis), Resident ID #1. Findings are as follows: Record review revealed that Resident ID #1 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, infection following a surgical procedure, rheumatoid arthritis and diabetes. Review of a community reported complaint submitted to the Rhode Island Department of Health on 6/26/2024 revealed that the resident had multiple concerns relative to the care s/he received while at the facility. Review of the physician orders revealed the following: -Humira subcutaneous pen -injector kit 40 MG (milligram)/0.8ML(milliliter) inject 1 application subcutaneously one time a day every 2 weeks on Friday. With a start date of 3/29/2024 and a discontinue (dc) date of 5/4/2024. -Humira subcutaneous pen-injector kit 40 MG/0.8ML inject 40 mg subcutaneously one time a day every 2 weeks on Friday. With a start date of 5/10/2024 and a dc date of 5/21/2024. -Humira subcutaneous prefilled syringe kit 40 MG/0.4ML inject 40 mg subcutaneously in the morning every 14 days. With a start date of 5/30/2024 and d/c date of 6/26/2024. Record review of the Medication Administration Records (MAR) for March, April, May and June of 2024 revealed the resident was not administered the medication for 3 of 6 opportunities on 3/29/2024, 4/12/2024 and 6/13/2024. Record review of the progress notes revealed that on the dates the Humira was scheduled but not administered staff documented that they were waiting for pharmacy to deliver the medication. Further record review failed to reveal evidence that the physician was informed that the resident did not receive his/her medication on the above-mentioned dates. During a surveyor interview with the Assistant Director of Nursing in the presence of the Director of Nursing Services on 7/23/2024 at 10:07 AM and 1:10 PM, she acknowledged the resident did not receive Humira as prescribed. Additionally, she stated that she would have expected the nurses to notify the physician of the missed doses.

Jun 2024 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

Quality of Care (Tag F0684)

A resident was harmed · This affected 1 resident

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan relative to monitoring and identifying a change in a resident's condition. Additionally, the facility failed to follow physician's orders relative to weekly weights, for 1 of 1 resident reviewed who exhibited increased swelling to his/her left leg and was diagnosed with a deep vein thrombosis (DVT- a blood clot). Resident ID #1. Findings are as follows: 1. Record review of a community reported complaint submitted to the Rhode Island Department of Health on 6/19/2024, alleges in part, Resident ID #1's left leg doubled in size due to increased swelling, was not having his/her weight monitored, and the facility was not ruling out blood clots, despite him/her having a history. According to Lippincott Manual of Nursing Practice 10th edition, 2014 published by Wolters Kluwer, pages 118 - 119 indicates that standards of care guidelines relative to preventing and recognizing complications after a person has surgery includes, but are not limited to, .Providing measures to enhance circulation of the lower extremities, such as .compression .and assess [monitor] for tenderness, swelling, and red streaking which may indicate DVT . Additionally, clinical signs of DVT include swelling of the entire leg. Prevention and management include assessing the lower extremity for circulation and sensation by checking for pulses of the leg and foot and for pain in the calf when the foot is moved upwards [Homan's sign] which may indicate DVT. Record review revealed that the resident was readmitted to the facility in May of 2024 with a diagnosis including, but not limited to, surgical repair of a left hip fracture and history of DVT. Record review of a nursing admission assessment dated [DATE] revealed, the resident presented with 3+ non-pitting edema (swelling that occurs in your feet, ankles, or legs. Non-pitting edema refers to when the edema is pressed with a finger and there is no lasting indentation in the skin. 3+ edema indicates severe edema and can take up to 30 seconds or more to rebound) to his/her left leg. Further record review of the care plan revealed the following: 5/8/2024, A focus area that indicates s/he has a history of DVT with interventions including, but not limited to: - Apply compression stockings if ordered - Monitor for pain in the leg, tenderness in the calf, leg tenderness, swelling of the leg, increased warmth, redness, skin discoloration or discomfort when the foot is pulled upwards may indicate a DVT 6/4/2024, A focus area that indicates s/he has a left hip fracture with interventions including, but not limited to: - Monitor circulation, motion, and sensation as ordered Record review revealed the following physical therapy treatment notes authored by Physical Therapy Assistant, Staff B, which states in part: 6/10/2024 - .Pt [patient] has L [left] lower leg/pedal [foot] edema. Pt noted throbbing pain left hip at rest, constant 10/10 pain during gait [walking]. Pt also made comment that [s/he] felt like hip 'the bone' would pop out. Nursing notified . 6/13/2024 - .L LE [lower extremity] with excessive swelling, Nursing notified . 6/14/2024 - .Pt notes L LE feels 'heavy' during gait . 6/17/2024 - .Pt was up in w/c [wheelchair] at time of rx [treatment]. Pt noted left knee pain during gait. Pt continues with excessive L LE swelling . Additional record review revealed the following progress notes which states in part: 5/25/2024 9:00 PM - nursing admission note, .+3 nonpitting edema to LLE .Pedal pulses are present and regular . 5/26/2024 2:53 PM - .Resident has LE discolorations, 2-3+edema, left> [greater than] R [right] . 5/27/2024 5:33 PM - provider telemedicine note, .Physical Exam: Exam findings per nurse Physical Exam - Notes: General resting comfortably in no acute distress CARDIO no edema . 5/28/2024 1:18 PM - .bilateral LE edema . 5/29/2024 2:51 PM - .left hip swollen, 2+ bilateral LE edema . 6/13/2024 5:42 PM - authored by LPN, Staff A, .Swelling present to residents LLE, NP evaluated this shift. NO [new order] for Lasix [a medication used to remove a buildup fluid in the body; also referred to as a water pill] .x [times] 14 days . 6/18/2024 3:59 PM - authored by LPN, Staff C, .LLE remains swollen, follow up with the Surgeon today, returned .order STAT [immediate] U/S [ultrasound] of LLE to R/O [rule out] DVT . 6/18/2024 6:10 PM - authored by Staff A, .Resident ultrasound to LLE, + [positive] DVT. MD contacted, new orders to send resident out to ER [emergency room] . Further record review failed to reveal evidence that the resident's left leg was monitored for increased warmth, redness, discoloration, or for discomfort when the foot is pulled upwards all of which would indicate the presence of a DVT, when s/he was noted with increased swelling. Additionally, the record failed to reveal evidence that an order was implemented for monitoring of circulation, motion, or sensation per the care plan. Lastly, the record failed to reveal evidence that the NP documented her evaluation of the resident on 6/13/2024. During a surveyor interview on 6/21/2024 at 11:41 AM with the NP, she revealed that she ordered the Lasix on 6/13/2024 when she was notified of the resident's increased left leg edema. She indicated that she evaluated the resident on 6/13/2024, however, she was unable to provide evidence of documentation of her assessment and findings. She indicated that she did not order an ultrasound on 6/13/2024 despite the resident having a history of DVT and recent surgery for the repair of a hip fracture. She acknowledged that she did not order the ultrasound until it was recommended by the resident's surgeon on 6/18/2024, 5 days after s/he was noted to have increased swelling of his/her left leg. During a surveyor interview on 6/21/2024 at 2:10 PM, with Licensed Practical Nurse, Staff A, the following was revealed: - On 6/13/2024 a physical therapist asked Staff A to see the resident because his/her left leg was swollen. Staff A indicated that she saw the resident's leg and notified the NP who gave an order for Lasix. - Additionally, Staff A was unable to provide evidence that she monitored the resident's circulation, motion, sensation, or for additional symptoms that may indicate a DVT. Furthermore, Staff A indicated that she was one of the nurses on duty when the resident was seen by his/her surgeon on 6/18/2024 for a follow up appointment. Staff A revealed that the resident returned to the facility with recommendations for an ultrasound to be completed immediately from the surgeon, to rule out a DVT. Staff A further revealed the ultrasound results were critical indicating multiple DVTs of the left lower extremity, which required the resident's transfer to an acute care hospital. Record review of the hospital documents revealed the following: - An ED triage note dated 6/18/2024 at 6:34 PM, indicates that the resident reported that s/he had been telling the nursing staff at the facility that his/her left leg was getting swollen. - An ultrasound of the resident's left lower extremity for DVT completed on 6/19/2024, which was positive for acute occlusive (blocked blood flow) blood clots in four major veins of the left lower extremity. S/he required high intensity intravenous blood thinning medication and transfer to a different acute care hospital for further management. - The resident was transferred to the other acute care hospital on 6/19/2024 and underwent a mechanical thrombectomy (medical procedure to remove blood clots). During a surveyor interview on 6/24/2024 at 10:21 AM with the Medical Director, he indicated that he would have expected the nurses would have monitored the resident for circulation, motion, and sensation in the residents left leg due to the increased swelling with his/her known history of DVT and recent surgery for a hip fracture. During surveyor interviews on 6/21/2024 at 12:12 PM and 6/24/2024 at 10:03 AM with the Assistant Director of Nursing (ADON), she revealed that she saw the resident before s/he left for his/her follow up appointment on 6/18/2024 and indicated that his/her left leg was discolored with increased swelling. She acknowledged and indicated that she would have expected the nurses to monitor the resident for signs that may indicate a DVT per the care plan and document the findings in the resident's medical record when s/he was noted with increased swelling on 6/13/2024. Additionally, the ADON was unable to provide evidence that the resident was monitored every shift since s/he was noted with increased swelling on 6/13/2024. Furthermore, she acknowledged that an ultrasound was not ordered until the surgeon recommended it on 6/18/2024, 5 days after the resident was noted with increased swelling. 2. Record review revealed a physician's order with a start date of 5/25/2024 indicating that the resident's weight should be obtained weekly for 4 consecutive weeks. Further record review of the May and June 2024 Treatment Administration Records revealed the following weights: 5/25/2024, 202.0 pounds (lbs.) 6/4/2024, 204.8 lbs. 6/11/2024, no evidence of a weight was documented. 6/18/2024, no evidence of a weight was documented. During a surveyor interview on 6/24/2024 at 10:03 AM, with the ADON, she was unable to provide evidence that the resident's weight was obtained as ordered on the above-mentioned dates. Additionally, she indicated that she would have expected the nurses to obtain the resident's weight as ordered. During a surveyor interview on 6/24/2024 at 10:21 AM with the Medical Director, he indicated that he would expect nursing staff to obtain the resident's weight as ordered. Additionally, he acknowledged that the resident's weight could have assisted in monitoring the change in his/her increased swelling and the effect of the water pill that the resident was prescribed.

May 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 surveyor observation, record review and staff interview it has been determined that the facility failed to protect and ...

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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 and keep residents free from physical abuse relative to an incident that occurred between Resident ID #1 and Resident ID #5. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 5/9/2024 revealed a nursing assistant (NA) entered Resident ID #5's room at 4:00 PM and observed Resident ID #1 with his/her hands around Resident ID #5's neck. The residents were immediately separated, and Resident ID #1 was sent to the hospital for an evaluation. Record review of the facility policy titled Resident Abuse, Neglect, Mistreatment and Misappropriation Prevention Policy dated April, 2015 states in part, Policy: Each resident has the right to be free from abuse .Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish . Record review revealed Resident ID #1 (the perpetrator) was admitted to the facility in March of 2022 with diagnoses including, but not limited to Alzheimer's disease, generalized anxiety disorder and major depressive disorder. Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating the resident has severe cognitive impairment. Further review of the assessment revealed the resident requires moderate assistance for functional abilities such as showering, dressing, toileting and limited assistance with personal hygiene. Additionally, the assessment indicates that s/he ambulates with a walker. Record review of Resident ID #1's care plan developed on 12/27/2023 and revised on 5/9/2024 states in part, [Resident] has potential to be physically aggressive r/t [related to] increase in confusion secondary to Alzheimer's dementia. [Resident] had an actual episode of physical aggression towards another resident . Record review revealed Resident ID #1 has been followed by psychiatric services, last assessed on 5/3/2024 in which s/he was noted to be alert, confused, and cooperative per baseline. Further review of the assessment revealed that staff had reported that the resident had increased confusion which could also be related to his/her diagnosis and a medical workup was completed with normal findings. Medication recommendations were made to start Buspar (medication to treat anxiety disorders) 5 mg daily, which was initiated on 5/4/2024. Record review revealed Resident ID #5 (the victim) was admitted to the facility in August of 2020 with diagnoses including, but not limited to, stroke, aphasia following a stroke, anxiety disorder and major depressive disorder. Record review of Resident ID #5's Quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status score of 2 out of 15, indicating severe cognitive impairment. Further review of the MDS assessment revealed the resident is dependent for most functional abilities, except for eating, which s/he can do independently. Additionally the assessment indicates that s/he is able to self-propel in his/her wheelchair on the unit. Record review of Resident ID #5's care plan developed on 12/27/2023 states in part, .[Resident] was involved in a resident to resident incident, interventions include room transfer and social services to provide support as needed . During a surveyor interview on 5/14/2024 at 9:16 AM with the Director of Nursing Services (DNS) she revealed Resident ID #1 is generally sweet, pleasantly confused and keeps to himself/herself, it is not his/her usual behavior to walk into another resident's room. She further revealed Resident ID #1 and Resident ID #5 had previously resided together as roommates until December of 2023. The residents were separated after Resident ID #1 hit Resident ID #5 with his/her walker and Resident ID #5 was moved into a different room. On the day of the incident, 5/9/2024 she revealed Resident ID #1 was observed by a staff member in Resident ID #5's room with his/her hands around Resident ID #5's neck. She further revealed staff intervened immediately and separated both residents. Resident ID #5 was placed in another room on the other end of the unit. Resident ID #1 was sent to the hospital for an evaluation where s/he was diagnosed with a urinary tract infection and received the first dose of a course of antibiotics before returning to the facility. Additionally, the DNS revealed on the following day Resident ID #5 was observed with a bruise to his/her left shoulder, an x-ray was ordered by the provider which resulted in negative findings. Furthermore, the DNS acknowledged the bruise on Resident ID #5's shoulder was from the incident on 5/9/2024. Record review of a progress note dated 5/9/2024, authored by the nurse that responded to the incident, revealed Resident ID #5 was observed with a superficial nail mark to his/her neck and a reddened area on his/her neck. During a surveyor interview on 5/14/2024 at 11:54 AM with the NA Staff A, who observed the incident between the two residents, she revealed Resident ID #1 is usually pleasantly confused and Resident ID #5 is sweet and keeps to himself/herself. Staff A revealed on the day of the incident she observed Resident ID #1 with her hands around Resident ID #5's neck, she immediately removed Resident ID #1 from Resident ID #5 and called for the nurse. Staff A took Resident ID #1 to his/her room and stayed with him/her until s/he left for the hospital. Resident ID #5 was moved to a room on the other side of the unit and then moved to a different floor. During a surveyor interview with the DNS on 5/14/2024 at 9:16 AM, she was unable to provide evidence that Resident ID #5 was kept free from abuse.

May 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

Infection Control (Tag F0880)

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 maintain a...

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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 maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections for 1 of 1 resident reviewed for the management of a Multidrug-resistant Organism (MDRO), Resident ID #1. Findings are as follows: Review of the Centers for Disease Control and Prevention (CDC) document titled, Multidrug-resistant organisms management (MDRO) states in part, .For ill residents (e.g., those totally dependent upon healthcare personnel for healthcare and activities of daily living use Contact Precautions [use of gown and gloves when entering a resident's room] .Implement Contact Precautions (CP) routinely for all patients colonized or infected with a target MDRO .modify CP to allow MDRO .colonized/infected patients whose site of colonization or infection can be appropriately contained and who can observe good hand hygiene practices to enter common areas and participate in group activities .No recommendation can be made regarding when to discontinue Contact Precautions . Review of the Center for Disease Control and Prevention document titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) Last Reviewed: August 1, 2023, states in part, Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities .The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents .with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: -Dressing -Bathing/showering -Transferring -Providing hygiene -Changing linens -Changing briefs or assisting with toileting . Review of a facility policy titled Isolation last revised 3/2024 states in part, Transmission-Based Precautions are for patients who are known or suspected to be infected or colonized with infectious agents, including certain epidemiologically important pathogens, which require additional control measures to effectively prevent transmission. Record review revealed that Resident ID #1 was readmitted to the facility in February of 2024 with diagnoses including, but not limited to, Alzheimer's disease, metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins), metastatic colon cancer, and anxiety disorder. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed s/he required moderate to maximum assistance to complete activities of daily living (ADLs). Additionally, the assessment revealed that the resident was frequently incontinent of bowel and bladder. Review of a urine culture obtained on 3/30/2024 revealed the resident is positive for Extended - spectrum beta-lactamase (ESBL - an MDRO infection that is resistant to many antibiotics). Surveyor observation of the resident's room on 5/1/2024 at 11:30 AM, failed to reveal evidence that the resident was on contact or enhanced precautions as there was no signage at the door, indicating that personal protective equipment was required during high-contact resident care activities. Review of a physician's order dated 4/2/2024 revealed an order for Amoxicillin (antibiotic) 500 milligrams three times a day for ESBL in the urine for 8 days. This order was started on 4/2/2024 and completed on 4/11/2024. During a surveyor interview on 5/1/2024 at approximately 1:45 PM with the resident's physician, he revealed that the was not called by staff, regarding removing the resident from precautions and that this was determined by the Infection Preventionist. During a surveyor interview on 5/1/2024 at approximately 2:00 PM with the Infection Preventionist (IP), Licensed Practical Nurse, she revealed that the resident was started on antibiotics on 4/2/2024 but not placed on contact precautions until 4/3/2023. The IP acknowledged that the resident is no longer on contact precautions for ESBL. A surveyor observation on 5/6/2024 at 1:30 PM, in the presence of Licensed Practical Nurse, Staff A, revealed Resident ID #1 had been place on Enhanced Barrier Precautions. There was signage now outside the resident's room with a bin of PPE at the doorway. Record review revealed a physician's order dated 5/1/2024 for Enhanced Barrier Precautions, after it was brought to the facility's attention.

Mar 2024 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

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 and staff interview it has been determined that the facility failed to keep a resident free from sexual a...

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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 keep a resident free from sexual abuse for 1 of 1 resident reviewed, Resident ID #4 and for 1 of 2 residents reviewed for physical abuse, Resident ID #2. Findings are as follows: 1. The State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023, states in part, .sexual contact is nonconsensual if the resident .lacks the cognitive ability to consent .CMS is not requiring facilities to adopt a specific approach in determining a resident's capacity to consent .in order to assist in the development and implementation of policy related to aspects of .intimacy and relationships .Allegations of Sexual Abuse .There are additional considerations when investigating allegations of sexual abuse involving .Resident to resident sexual abuse . For any alleged violation of sexual abuse, the facility must: - Immediately implement safeguards to prevent further potential abuse; - Immediately report the allegation to appropriate authorities; - Conduct a thorough investigation of the allegation; and - Thoroughly document and report the result of the investigation of the allegation . Record review revealed Resident ID #4, the alleged victim, was admitted to the facility in March of 2021 with diagnoses including, but not limited to, dementia and cognitive communication deficit. Record review of a Quarterly Minimum Data Set (MDS) Assessment for Resident ID #4 dated 2/26/2024, revealed a Brief Interview for Mental Status (BIMS) score of 2 out of 15 indicating severely impaired cognition. Record review revealed Resident ID #1, the alleged perpetrator, was admitted to the facility in February of 2024, with diagnoses including, but not limited to, dementia without behavioral disturbance and mild neurocognitive disorder. Record review of an admission MDS Assessment for Resident ID #1 dated 2/28/2024, revealed a BIMS score of 3 out of 15, indicating severely impaired cognition. Record review of the admission progress note dated 2/19/2024 at 2:57 PM for Resident ID #1, revealed that according to the hospital report the resident was admitted to the hospital from his/her previous nursing facility secondary to sexually inappropriate behaviors with another resident. Further review of Resident ID #1's progress notes revealed: -2/22/2024 at 2:46 PM, late entry, authored by the Nurse Practitioner [NP] past medical history includes advance dementia, inappropriate sexual behaviors, intrusive and impulsive toward opposite sex. Today s/he has increased inappropriate sexual behaviors towards opposite sex residents and the staff. -2/22/2024 at 1:57 PM - Resident had to be redirected several times due to him/her approaching other residents and pushing them down the hall in their wheelchairs. Staff asked him/her to stop, and s/he did for only a few minutes. S/he would mumble back under his/her breath I will leave them alone now, but I'll come back. S/he also had words for the staff after looking at their buttocks. This writer called the NP to see what she wanted to do, the residents are unable to defend themselves or to verbally tell this resident to leave them alone. -2/24/2024 1:19 AM -Resident was reported at 4:00 PM in dining room kissing and touching another resident, Resident ID #4. -2/26/2024 12:07 AM -This evening grabbed a patient by his/her hand and was walking him/her to his/her room. During a surveyor observation on 3/1/2024 at 1:00 PM, Resident ID #1 and #4 were observed to be seated together in the dining room. During a surveyor interview with Nursing Assistant (NA), Staff A, following the above observation, she revealed that she had observed Resident ID #1 have a sexually inappropriate interaction with Resident ID #4 stating in part, I have seen it a couple of times [Resident ID #1] rubs [Resident ID #4's] thighs. Staff A was unable to state the exact day and time this interaction was observed. She further indicated she was told It's okay by the nurses. Staff A was unable to identify who the nurses were that stated this behavior was acceptable. During a surveyor interview on 3/1/2024 at approximately 1:10 PM with Licensed Practical Nurse (LPN), Staff B, she indicated she was aware of Resident ID #1's inappropriate sexual behaviors and indicated the staff were completing 15-minute checks on the resident. Staff B then provided the surveyor a document titled check every 15 minutes for Resident ID #1. This document was started on 2/25/2024 and was missing documentation on 2/28/2024 between 6:30 AM until 2:45 PM, and 3/1/2024 between 11:15 AM until 1:10 PM. Staff B acknowledged that the 15-minute checks were not completed for the above-mentioned dates and times. Lastly, she was unable to provide evidence that Resident ID #1 received 15-minute checks prior to 2/25/2024, five days after his/her admission. Additional record review failed to reveal interventions to mitigate the risk of his/her behaviors to other residents in the facility or interventions for staff to implement/utilize to ensure the safety of the other residents residing in the facility prior to 2/25/2024, five days after his/her admission. During a surveyor interview on 3/1/2024 at 2:22 PM, with LPN, Staff C, she revealed that on 2/24/2024, she witnessed Resident ID #s 1 and 4 in the dining room together. She indicated that she saw Resident ID #1 kissing Resident ID #4 and touching his/her back and shoulders in an inappropriate manner. She further revealed that she was directed not to separate the residents as they are two consenting adults. Lastly, she stated that she informed the Nursing Supervisor, Staff D. During a surveyor interview on 3/4/2024 at 1:31 PM with Nursing Supervisor, Staff D, she revealed that she had observed Resident ID #1 touching Resident ID #4's thighs in an inappropriate manner in the dining room. She was unable to state what date and time this occurred. Additionally, she revealed she believed she witnessed this during her shift the weekend of 2/24/2024. She revealed she was told not to separate the residents by another nurse. During a surveyor interview on 3/1/2024 at 2:49 PM with the Administrator, he acknowledged that Resident ID #1 had kissed Resident ID #4 on 2/24/2024. Additionally, he stated in part, .[s/he] was trying to lure .residents to [his/her] room .once we knew how [the resident] was we put 15-minute checks on after we knew how [s/he] was . During a surveyor interview on 3/1/2024 at 2:22 PM with Social Worker, Staff E, she indicated that she was not aware of the interactions between Resident ID #1 and #4 until it was brought to her attention by the surveyor. Additionally, she revealed her normal practice is to follow-up with the victim and/or their family. During a surveyor interview on 3/1/2024 at 3:45 PM with the DNS, she revealed that she was aware that Resident ID #1 was kissing Resident ID #4 from his/her progress note. She further revealed that her expectation would be that 15-minute checks would be completed and documented. Record review reveals a progress note on 3/3/3024 at 2:23 PM (after the facility was aware of these behaviors) Resident ID #1 was observed stroking the cheek of a resident of the opposite sex. During a surveyor interview on 3/4/2024 at 1:37 PM with the Nurse Practitioner, she revealed that she is the provider for both Resident ID #s 1 and 4. She revealed that the staff failed to notify her about the kissing and touching between Resident ID #1 and 4. Additionally, she revealed that she would have expected to be notified of this incident as Resident ID #4 is unable to consent to sexual intimacy due to his/her cognitive status. During a surveyor interview on 3/4/2024 at 12:58 PM with the Administrator, he was unable to provide evidence that Resident ID #4 was kept free from sexual abuse. 2. Record review of a facility reported incident submitted to the Rhode Island Department of Health on 2/20/2024 indicates that on 2/20/2024, Resident ID #3 reported that Resident ID #2 came into his/her room. Resident ID #3 told him/her to get out and then Resident ID #2 proceed to hit Resident ID #3 on the right forearm. Review of a facility policy titled, Abuse Prevention, Neglect, mistreatment and misappropriation prevention policy dated April 2015, states in part, .Each resident has the right to be free from abuse .It is the policy of all [name redacted] Health Care Systems facilities to implement policies to .identify, investigate and report allegations of abuse .employees are expected to identify and report potential or actual occurrences of abuse . Record review of a progress note dated 2/21/2024 at 12:18 AM, revealed the nurse was notified that Resident ID #2 hit Resident ID #3 in the right forearm. Record review revealed Resident ID #3 was admitted to the facility in October of 2022 with diagnoses including, but not limited to anxiety and major depressive disorder. Record review of a quarterly MDS assessment dated [DATE], revealed a BIMS score of 15 out of 15 indicating that the resident has intact cognition. Record review of a psychological services progress note dated 2/27/2024, states in part, .Resident was requesting to be seen due to increased anxiousness. Staff also reported an incident that occurred days ago where this resident was attacked by another resident. During session, resident reported 'I'm trying to get over it, ill get over it' [S/he] reported some PTSD [post-traumatic stress disorder] and nervousness from the incident . During a surveyor interview on 3/1/2024 at 11:45 AM with Resident ID #3 s/he revealed that several days ago Resident ID #2 hit him/her in the wrist with his/her walker. Record review revealed Resident ID #2 was admitted to the facility in February of 2024 with diagnoses including, but not limited to dementia, anxiety, mild neurocognitive disorder with behavioral disturbance (reduced cognitive capacity) and schizoaffective disorder (a mental health condition). Record review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 3 out of 15 indicating severe cognitive impairment. Additional review reveals s/he ambulates supervised with a rolling walker. Further review of Section E-Behaviors revealed the resident exhibits both physical and verbal behaviors. During a surveyor interview on 3/1/2024 at 10:27 AM with the Director of Nursing Services she acknowledged that the incident did occur. Additionally, she was unable to provide evidence that Resident ID #3 was kept free from abuse. Cross Reference: F 609 and F 655

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, resident, and staff interview, it has been determined that the facility failed to ensure that all allege...

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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 all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made to the State Agency in accordance with State law for 1 of 1 resident reviewed for sexual abuse, Resident ID #4. Findings are as follows: The State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023, states in part, .sexual contact is nonconsensual if the resident .lacks the cognitive ability to consent . Review of a facility policy titled, Abuse Prevention, Neglect, mistreatment and misappropriation prevention policy dated April 2015, states in part, .Each resident has the right to be free from abuse .It is the policy of all [NAME] Health Care Systems facilities to implement policies to .identify, investigate and report allegations of abuse .employees are expected to identify and report potential or actual occurrences of abuse . Record review revealed Resident ID #4, the alleged victim, was admitted to the facility in March of 2021 with diagnoses including, but not limited to, dementia and cognitive communication deficit. Record review of a Quarterly Minimum Data Set (MDS) Assessment for Resident ID #4 dated 2/26/2024 revealed a Brief Interview for Mental Status (BIMS) score of 2 out of 15 indicating severely impaired cognition. Record review revealed Resident ID #1, the alleged perpetrator, was admitted to the facility in February of 2024, with diagnoses including, but not limited to, dementia without behavioral disturbance and mild neurocognitive disorder. Record review of an admission MDS Assessment for Resident ID #1 dated 2/28/2024, revealed a BIMS score of 3 out of 15, indicating severely impaired cognition. Record review of Resident ID #1's progress note dated 2/24/2024 at 1:19 PM revealed in part that at 4:00 PM s/he was reported to be kissing and touching another resident, Resident ID #4 in the dining room. During a surveyor interview on 3/4/2024 at 1:37 PM with the Nurse Practitioner, she revealed that she is the provider for both Resident ID #s 1 and 4. She revealed that the staff failed to notify her about the kissing and touching between Resident ID #1 and 4. Additionally, she revealed that she would have expected to be notified of this incident as Resident ID #4 is unable to consent to sexual intimacy due to his/her cognitive status. During a surveyor interview with the Administrator on 3/1/2024 at 3:45 PM, he acknowledged the above-mentioned incident occurred. Additionally, he was unable to provide evidence that the incident was reported. Cross Reference to F 600

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 F0655 (Tag F0655)

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 baseline ...

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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 baseline care plan for each resident within 48 hours of a resident's admission, that includes the instructions needed to provide effective and person-centered care for 1 of 1 resident reviewed with inappropriate sexual behaviors, Resident ID #1. Findings are as follows: According to the State Operations Manual, Appendix PP- Guidance to Surveyors for Long Term Care Facilities, revised on 2/3/2023, §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must- (i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- (A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable . Record review revealed Resident ID #1, was admitted to the facility in February of 2024, with diagnoses including, but not limited to, dementia without behavioral disturbance and mild neurocognitive disorder. Record review of the admission Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 3 out of 15, indicating severely impaired cognition. Record review of the admission progress note dated 2/19/2024 at 2:57 PM, revealed that according to the hospital report the resident was admitted to the hospital from his/her previous nursing facility secondary to sexually inappropriate behaviors with another resident. Record review of the resident's baseline care plan dated 2/19/2024, failed to reveal implementation of any interventions for his/her sexually inappropriate behaviors. During a surveyor interview on 3/1/2024 at approximately 3:45 PM with the Director of Nursing Services, she indicated the nurses on the units are expected to complete the residents' baseline care plans upon admission. Additionally, she acknowledged that Resident ID #1's baseline care plan did not reflect interventions for his/her inappropriate sexual behaviors. Cross Reference: F 600 and F 609

Sept 2023 10 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, it has been determined that the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 7 residents reviewed for positioning, Resident ID #73. Findings are as follows: Record review revealed the resident was readmitted to the facility in July of 2021 with diagnoses including, but not limited to, stroke, hemiplegia and hemiparesis affecting the left side (weakness and paralysis on one side of the body). 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 intact cognition. Additionally, the MDS revealed s/he requires total assistance of two or more staff members for transferring and locomotion. Record review of a care plan dated 8/31/2022 revealed the resident has contractures (tightening of the muscle causing difficulty with movement) of the left arm and bilateral knees. Interventions include to apply devices as indicated. Further record review of a progress note dated 8/1/2023 at 4:07 PM revealed the resident complained of discomfort while sitting in his/her wheelchair. Additionally, the note indicated that s/he had to be transferred back to bed for repositioning. Record review of a document titled, PHYSICAL THERAPY Discharge Summary, dated 8/31/2023 revealed that the resident received physical therapy services from 7/26/2023 through 8/31/2023 for wheelchair positioning due to [his/her] complaints of discomfort while sitting in [his/her] high back reclining wheelchair. The document states in part, .pt [patient] able to sit in high and reclining back w/c [wheelchair] with w/c positioning aides provided: R [right] lateral trunk support, extended calf and foot rest support with divider and LUE [left upper extremity] bolster .Pt. expressing no discomfort . Additionally, the document indicated the resident's prognosis to maintain current level of functioning is good with consistent staff follow through and continuation of wheelchair components to maintain positioning and comfort. Record review of the document titled, RESIDENT CARE CARD, dated 8/4/2023 failed to reveal evidence of the positioning devices the resident requires while sitting in his/her wheelchair. During a surveyor observation on 9/27/2023 from 10:47 AM until 11:00 AM, revealed the resident was seated in his/her wheelchair, leaning to his/her right side. Additionally, the resident's right foot was off the foot rest and his/her left foot was observed resting on a black cushion which was on the wheelchair footrest. During a surveyor interview on 9/27/2023 at 11:00 AM with the resident, s/he reported to the surveyor that s/he was experiencing lower back pain due to the way s/he was positioned in the wheelchair. The surveyor immediately notified the nurse on duty, Registered Nurse, Staff B. During a surveyor observation on 9/27/2023 at 11:03 AM the resident was observed to be in the same position as mentioned above and was also observed to have a grimaced look on his/her face. During a subsequent surveyor interview on 9/27/2023 immediately following the above-mentioned observation with Staff B, she stated, I called therapy to come up and see [him/her] because they help with positioning [him/her] in the wheelchair. Additionally, Staff B acknowledged that she did not go into the dining room to assess the resident. During a surveyor observation on 9/27/2023 at 11:06 AM, the resident was observed to be positioned in the same manner with his/her right foot off of the foot rest and the left foot on top of a black square cushion. At this time the Rehabilitation Director entered the dining room. During a surveyor interview on 9/27/2023 at 11:06 AM with the Rehabilitation Director, she indicated that the black square cushion was placed incorrectly, which she then adjusted. Surveyor observation on 9/27/2023 at 11:09 AM revealed the Rehabilitation Director and an additional therapy staff member repositioning the resident in his/her wheelchair by removing the right lateral cushion and they indicated the cushion had been placed incorrectly. During a surveyor interview on 9/27/2023 at 11:21 AM with the Rehabilitation Director, she acknowledged that the positioning devices were placed incorrectly. She indicated that the lateral support on the right side was placed upside down and the divider cushion was not between the resident's feet. During a surveyor interview on 9/27/2023 at 11:25 AM with Staff B, she acknowledged that she did not go into the dining to assess the resident. Additionally, she acknowledged that if she did assess the resident, she would have identified that the cushions were placed incorrectly. Further, she indicated that she did not inform the Nursing Assistant (NA) of how to properly position the resident's devices at the beginning of the shift. During a surveyor interview on 9/27/2023 at 11:34 AM with the resident's NA, Staff I, she indicated that she was unaware of how the resident's positioning devices should be placed. Additionally, she indicated that she did not receive information on the positioning devices from her nurse at the beginning of the shift. During a surveyor interview on 9/27/2023 at 11:54 AM, with the Director of Nursing Services, she indicated that she would have expected staff to receive education on how to properly place the positioning devices for the resident. Additionally, she was unable to provide evidence that staff were educated on how to properly place the positioning devices.

CONCERN (D)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure residents that are fed through a feeding tube receive the appropriate treatm...

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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure residents that are fed through a feeding tube receive the appropriate treatment and services to prevent complications for 1 of 2 residents reviewed who receive nutrition via a feeding tube, Resident ID #85. Findings are as follows: Record review revealed the resident was admitted to the facility in February of 2023 with diagnoses including, but not limited to, adult failure to thrive and Alzheimer's disease. Record review of a physician order dated September 2023 states in part, .Jevity 1.2 Cal (a high protein, fiber fortified liquid nutritional supplement) Oral Liquid Nutritional Supplement Bolus (a method of manually providing formula through a feeding tube) 240 ml (milliliters) four times a day . Record review of the manufacturer instructions on the Jevity 1.2 Cal 1000 ml container states in part, .once opened, reclose, refrigerate, and use within 48 hours . Surveyor observation on 9/26/2023 at approximately 2:30 PM revealed Licensed Practical Nurse, Staff D, was administering 240 ml of Jevity 1.2 Cal., from a previously opened bottle located at the resident's bedside. Further observation revealed the bottle did not have a date or time written on it to indicate when it was opened. During a surveyor interview on 9/26/2023 at approximately 2:40 PM with Staff D, she revealed she opened the container of Jevity 1.2 at 8:30 AM and it had not been refrigerated. This indicates that the container had been at the bedside unrefrigerated for approximately 6 hours. During a surveyor interview on 9/26/2023 at approximately 2:49 PM with the Director of Nursing Services, she revealed she would expect the manufacturer instructions to be followed for the Jevity.

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

Respiratory Care (Tag F0695)

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 receives necessary respiratory care and services that ar...

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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 receives necessary respiratory care and services that are in accordance with professional standards of practice for 2 of 2 residents reviewed for respiratory care, Resident ID #s 10 and 41. Findings are as follows: Record review of the facility policy titled, OXYGEN ADMINISTRATION NASAL CANNULA states in part, .To deliver low flow oxygen, per the physician's order .via nasal cannula .Set the Oxygen liter flow to the prescribed liters flow per minute .Replace and date cannula and tubing weekly or when visibly soiled or damaged . 1. Record review revealed Resident ID #10 was admitted to the facility in October of 2022 with diagnoses including, but not limited to, chronic obstructive pulmonary disease with acute exacerbation. Surveyor observations of the resident revealed s/he was receiving oxygen therapy via nasal cannula at 1 liter per minute on the following dates and times: 9/25/2023 at 10:12 AM 9/26/2023 at 9:09 AM 9/27/2023 at 10:00 AM Record review failed to reveal evidence of a physician's order for oxygen therapy. During a surveyor interview on 9/27/2023 at 3:25 PM with Licensed Practical Nurse, Staff J, she was unable to provide evidence of an order for oxygen therapy. Record review revealed a physician's order obtained on 9/27/2023 at 11:00 PM for oxygen at 2 liters via nasal cannula. Subsequent surveyor observation on 9/28/2023 at approximately 9:15 AM revealed the resident was receiving oxygen at 3 liters via nasal cannula. 2) Record review revealed Resident ID #41 was admitted to the facility in March of 2015 with diagnoses including, but not limited to, Alzheimer's disease and anxiety disorder. Record review revealed the following physician's orders: -12/13/2022, Oxygen via nasal cannula at 2 liters/minute. -8/1/2020, Change oxygen tubing every Saturday on the 11:00 PM-7:00 AM shift. Surveyor observations of the resident revealed s/he was receiving oxygen therapy via nasal cannula at 3.5 liters per minute on the following dates and times: 9/25/2023 at 8:47 AM 9/28/2023 at 8:58 AM Observation of the oxygen tubing during the above observations revealed a piece of tape with the date 9/17/2023, indicating that the tubing was changed on 9/17/2023. During a surveyor interview and observation on 9/28/2023 at 9:02 AM, with Licensed Practical Nurse, Staff K, she acknowledged that the oxygen was at 3.5 liters per minute and that the oxygen tubing was last changed on 9/17/2023.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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

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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 has failed to ensure that residents are free of any significant medication errors for 1 of 7 residents reviewed relative to medication administration, Resident ID #103. Findings are as follows: Record review revealed the resident was admitted to the facility in July of 2023 with diagnoses including, but not limited to, hyperosmolality (condition where the blood has a high concentration of solutes) and Hypernatremia (increased sodium concentration in the blood), alcohol abuse with alcohol -induced psychotic disorder, and liver disease. Record review of a laboratory report dated 9/26/2023, states in part, .L[low] potassium 3.1 MEQ/L [milliequivalents/liter]. Additionally, instructions handwritten at the bottom of the report reads, Potassium 40 MEQ tonight only .Potassium 10 MEQ [NAME] [daily] . Record review of the September 2023 Medication Administration Record (MAR) revealed an order dated 9/26/2023 to administer Potassium Chloride extended release 20 MEQ 1 tablet one time only for low potassium. This was documented as a 9 on 9/26/2023, which under a section of the MAR titled, chart codes indicates other/see nurses notes. Record review of a progress note dated 9/26/2023 at 5:10 PM authored by Registered Nurse, Staff E, states in part, Labs reported to [provider]. New orders: Give potassium 40 mEq tonight and start potassium 10mEq daily for low potassium 3.1 . During a surveyor interview on 9/28/2023 at 12:42 PM with Staff E, he revealed that the order was obtained for Potassium 40 mEq for the first dose. Staff E further acknowledged that he had transcribed Potassium 20 mEq give one tablet in error, instead of two tablets to make up the ordered 40 mEq dose. During a surveyor interview on 9/28/2023 at approximately 1:00 PM with Advance Practice Registered Nurse, Staff L, she revealed that she ordered Potassium 40 mEq to be administered on 9/26/2023, due to the lab work obtained which indicated a low potassium level. She further revealed that she was unaware that the resident did not receive the potassium as ordered.

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 F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

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

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Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 1 resident observed to have their call light placed out of their reach, Resident ID #23. Findings are as follows: According to the facility policy titled, Call Light, Use Of, dated April 2015, states in part, .resident/patients will have a call light or alternative communication device within his/her reach when unattended .When providing care to residents/patients be sure to position the call light conveniently, telling/showing resident/patient where the call light is located . Record review revealed the resident was admitted to the facility in June of 2011 with diagnoses including, but not limited to, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following a stroke affecting the right dominant side. Record review revealed a care plan for an activities of daily living deficit related to right sided paralysis secondary to a stroke. Surveyor observations revealed the resident's call light was placed on the right side of the bed out of the resident's reach, on the following dates and times: -9/25/2023 at 10:45 AM -9/26/2023 at 8:19 AM, 8:26 AM, 8:35 AM, 8:37 AM and 8:50 AM During a surveyor interview on 9/26/2023 at 8:50 AM with Nursing Assistant, Staff P, he acknowledged that the call light was out of the resident's reach. He further revealed that the resident is paralyzed on the right side. Surveyor observations on 9/28/2023 at 8:32 AM, 8:35 AM and 8:43 AM revealed the resident's call light was placed on his/her right side of the bed out of the resident's reach. During a surveyor interview on 9/28/2023 at 8:43 AM with Registered Nurse, Staff B, she acknowledged that the resident's call light was out of his/her reach, due paralysis of his/her right side. During a surveyor interview on 9/28/2023 at 9:29 AM with the Director of Nursing Services, she revealed that she would expect the resident's call light to be within reach and accessible to the resident.

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

Report Alleged Abuse (Tag F0609)

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 all allege...

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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 all alleged violations involving abuse, including injuries of unknown source 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 other officials (Department of Health), in accordance with State law for 1 of 1 resident reviewed for misappropriation, and 1 of 1 resident reviewed for injury of unknown origin, Resident ID #s 7 and 20. Findings are as follows: Record review of the facility policy titled, ABUSE PROHIBITION POLICY states in part, .Reporting/Documentation Requirements .The Administrator, Director of Nursing or their designee assumes responsibility for the immediate verbal notification of the incident to the following .3. The Department of Public Health: All alleged violations involving abuse, neglect exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not 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 Administrator of the facility and to other officials .in accordance with State law .Rhode Island .The licensing agency report form will be sent via fax .The facility shall maintain evidence that the allegation of abuse, neglect, exploitation and/or mistreatment has been thoroughly investigated and reported to Department of Public Health within 5-business days . 1. Record review for Resident ID #7 revealed s/he was admitted to the facility in August of 2016 with diagnoses including, but not limited to, multiple sclerosis, major depressive disorder, and generalized anxiety disorder. Record review of a quarterly Minimum Data Set assessment dated [DATE] revealed the resident has a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that s/he is cognitively intact. During a surveyor interview on 9/29/2023 at 8:33 AM with the resident, s/he revealed that a couple of months ago s/he had stamps and 9 dollars that went missing. During a surveyor interview on 9/26/2023 at 2:56 PM with Social Worker, Staff A, she revealed that on 6/30/2023 the resident stated s/he was missing a book of stamps and a DVD. During a surveyor interview on 9/26/2023 at 3:11 PM with the Administrator, he could not provide evidence that the misappropriation was reported as required by law and as indicated in the facility policy. 2. Record review for Resident ID #20 revealed s/he was admitted to the facility in May of 2018 with diagnoses including, but not limited to, vascular dementia with behavioral disturbance, psychotic disorder with delusions, and major depressive disorder. Record review of a quarterly Minimum Data Set assessment dated [DATE] revealed that a BIMS was unable to be completed because the resident is .rarely /never understood . Record review of a document titled, Interim Skin Audit dated 8/8/2023 stated in part, .left breast bruise 2.5 cm [centimeters] x [by] 1 cm .right breast bruise 2.3 cm x 1.1 cm. Record review of a nursing post event progress note dated 8/8/2023 stated in part, .CNA [Certified Nursing Assistant] reported to this writer that resident has bruising on [his/her] chest. Resident assessed .Reported to [Nurse Practitioner] advising to monitor the area . During a surveyor interview on 9/28/2023 at 11:00 AM with the Director of Nursing Services, she was unable to provide evidence that the injury of unknown origin was reported as required by law and as indicated in the facility policy.

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 surveyor observation, record review and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to physician's orders, for 1 of 2 r...

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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to physician's orders, for 1 of 2 residents with recommendations from an outside consultant, Resident ID #35, 1 of 7 residents reviewed for medication administration, Resident ID #107, 4 of 13 residents with an air mattress, Resident ID #s 11, 58, 73, and 102, and 1 of 1 resident observed during a wound treatment, Resident ID# 88. Findings are as follows: A. 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 #35 was admitted to the facility in June of 2022 with diagnoses including, but not limited to, adult failure to thrive and moderate protein-calorie malnutrition (under nutrition). Review of a physician's order dated 4/10/2023 states, Consult- GI [gastroenterology] specialist r/t [related to] need for colonoscopy. Record review of the GI Continuity of Care consult document, dated 7/12/2023, revealed the following recommendations were made; obtain lab work for TTGAB (blood testing for auto immune disease), TSH (a blood test to measure the thyroid), stool culture, ova and parasite, giardia, and c-diff (stool tests). Additionally, recommendations were made for the following: Start fiber powder such as Metamucil daily, avoid Milk of Magnesia and Senna. Record review failed to reveal evidence that the recommended lab work was obtained until 6 weeks after the recommendation was made on 8/22/2023 and 8/23/2023. Record review of the physician's orders from 7/12/2023 through 9/19/2023, failed to reveal evidence that the fiber powder was initiated for the resident. Record review revealed the resident had a subsequent follow up consult with the GI specialist on 9/20/2023. Review of the GI Continuity of Care consult document, dated 9/20/2023, revealed the following recommendations: Stop Senna and Milk of Magnesia. Start fiber powder one tablespoon psyllium husk daily such as Metamucil daily. Additionally, obtain stool studies for stool culture and elastase (pancreatic function test) and obtain lab work for the following: TTG Ab, TSH, CMP (test that measures the body's fluid balance and how well the kidneys and liver are working), CBC, CRP (test for inflammation). Record review of the July through September 2023 Medication Administration Records (MARs) failed to reveal evidence that the milk of magnesia or the Senna orders were discontinued prior to 9/20/2023, after a second request was made by the GI specialist. Record review failed to reveal evidence that the 9/20/2023 lab orders were transcribed or completed. During a surveyor interview on 9/27/2023 at 11:16 AM with Registered Nurse, Staff B, she acknowledged that the lab work requested by the GI specialist on 7/12/2023 was not completed until 8/22/2023 and 8/23/2023. Additionally, she acknowledged that the labs requested by the GI specialist on 9/20/2023 were not transcribed or completed, until brought to her attention by the surveyor. During a surveyor interview on 9/27/2023 at approximately 1:30 PM with the Advance Practice Registered Nurse (APRN), Staff C, she revealed that she would have expected the above-mentioned lab work requested on 9/20/2023 to have been transcribed and completed within one week of seeing the specialist. During a surveyor telephone interview on 9/28/2023 at 10:09 AM with the GI specialist, she revealed that she would have expected the lab work and the medication recommendations to have been completed within one week of consulting with the resident. Additionally, the GI specialist repeated the recommendations for the lab work because the facility never provided her with the results from the resident's initial visit on 7/12/2023. During a surveyor interview on 9/28/2023 at approximately 1:09 PM with the facility Medical Director, he revealed that any recommendations made by specialists are followed. Additionally, he would expect that the GI medication recommendations would be initiated immediately and that the lab work would be completed within a week of the recommendations. During a surveyor interview on 9/28/2023 at approximately 2:27 PM with the Director of Nursing Services (DNS), she acknowledged that the resident's fiber order was not initiated until 9/20/2023 and that the Senna and Milk of Magnesia medication orders were not discontinued after the initial consult on 7/12/2023. Additionally, the DNS was unable to explain why the 7/12/2023 lab work recommendations were not obtained until 8/22/2023 and 8/23/2023. Further, she was unable to explain why the lab work ordered on 9/20/2023 from the GI specialist was not completed by the facility. Lastly, the DNS revealed her expectation is that the recommendations from the specialist would be implemented. 2. Record review revealed Resident ID #88 was re-admitted to the facility in March of 2023 with diagnoses including, but not limited to, dementia and a wound to his/her coccyx (tailbone). Record review revealed a physician's order dated 9/26/2023 for the coccyx wound, cleanse with wound cleanser, gently pat dry, apply skin prep to the peri wound and pack the wound bed with Opticell sliver and cover with foam dressing, in the evening every 3 days. During a surveyor observation on 9/27/2023 at 10:37 AM of the wound treatment being completed by Licensed Practical Nurse, Staff D, revealed she failed to apply the skin prep to the peri wound as ordered. During a surveyor interview on 9/27/2023 at 10:55 AM with Staff D, she acknowledged that she did not apply the skin prep as ordered. B. According to Basic Nursing, Mosby's, 3rd, the five guidelines to ensure safe drug administration include the right drug, the right dose . Record review revealed Resident ID #107 was re-admitted to the facility in September of 2023 with diagnoses including, but not limited to, malignant neoplasm of the connective and soft tissues, intraabdominal swelling, and a low protein level. Record review revealed a physician's order dated 9/26/2023 for liquid ProSource one time a day for low protein 5.7, Albumin [protein found in plasma] 3.0. Additionally, the order failed to reveal a dose for the protein supplement. During a surveyor interview with Registered Nurse, Staff E, the nurse that transcribed the liquid ProSource order, he revealed that the order should have included a dose of 30 milliliters (ml). Record review of the September 2023 MAR revealed the liquid ProSource was signed off as administered on 9/26, 9/27, and 9/28/2023, without a dose included in the order. During a surveyor interview on 9/28/2023 at 12:01 PM with the Assistant Director of Nursing (ADNS), she acknowledged that the liquid Prosource order did not include a dose and further revealed the order should include a dose for how many milliliters are to be administered. C. According to Basic Nursing, Mosby, 3rd, the registered nurse checks all transcribed orders against the original order for accuracy and thoroughness, if the order seems incorrect or inappropriate, the nurse consults the physician . Review of the facility Policy and Procedure titled, Alternating Pressure Air Mattress, dated April 2015, states in part, POLICY to maintain adequate circulation, relieve pain due to pressure and aid in healing and/or prevention of pressure ulcers [localized damage to the skin and/or underlying soft tissue usually over a bony prominence] .PROCEDURE Verify MD Order and settings according to manufacturer guidelines .plug unit to electrical outlet. Press ON switch and check indicator light to ensure pump is on. Light indicates pump is operating .Check settings and function regularly, and place setting on the pump .Document settings on care plan, care card and TAR [treatment administration record] . 1. Record review revealed Resident ID #11 was admitted to the facility in February of 2013 with a diagnosis including, but not limited to, chronic pain. Record review revealed an order dated 1/18/2021 for a specialty air mattress, check setting and function every shift. Record review revealed a care plan with a focus for being at risk for skin breakdown due to incontinence, with a revised intervention date of 5/12/2021 to include a specialty air mattress check setting and function every shift. The care plan failed to reveal evidence of a setting for the air mattress. During a surveyor observation and simultaneous interview on 9/25/2023 at 12:04 PM with the resident, revealed the air mattress setting was set to 200 pounds (lbs.), static. Further observation revealed three stickers affixed to the air mattress pump with writing on them, one sticker indicated alt[alternating]/200, another sticker read alt/150, and the third sticker read setting: 200. Additionally, the resident revealed the mattress setting hasn't changed and it is not comfortable. During subsequent surveyor observations on the following dates and times revealed the air mattress setting was set to 200 lbs., static: -9/26/2023 at approximately 11:45 AM -9/27/2023 at 9:28 AM -9/28/2023 at 8:50 AM -9/28/2023 at 9:13 AM During a surveyor observation and simultaneous interview on 9/28/2023 10:47 AM with Registered Nurse, Staff B, she revealed the air mattress setting should be set to static and his/her weight should set to 200 lbs. Additionally, she revealed that she checks the function and setting by making sure the mattress is inflated and refers to the sticker for the setting. Further, she was not able to explain why the setting was set to static or what the current air mattress setting should be for the resident. Additionally, she would refer to the Maintenance Assistant. During a surveyor interview on 9/28/2023 at 9:33 AM with the Maintenance Assistant, Staff F, he revealed that maintenance adjusts the setting to the air mattresses by the resident's weight. Additionally, if the resident has no wounds, the air mattress setting is set to static. During a surveyor interview on 9/28/2023 at 12:01 PM with APRN, Staff C, she revealed that she would expect the resident's air mattress setting to be on alternating pressure and not set to static. 2. Record review revealed Resident ID #58 was re-admitted to the facility in May of 2023 with diagnoses including, but not limited to, paraplegia (paralysis that affects the ability to move the lower portion of the body) and scoliosis (curvature of the spine). Record review revealed an order dated 6/9/2023 for a specialty air mattress, check setting and function every shift. Record review revealed a care plan with a focus for being at risk for a pressure ulcer due to decreased mobility and a history of pressure ulcers, with a revised intervention date of 5/12/2021 to include a specialty air mattress check setting and function every shift. The care plan failed to reveal evidence of a setting for the air mattress. During an interview with the resident on 9/25/2023 at 10:00 AM, s/he indicated that his/her air mattress was uncomfortable and causing pain. Additionally, s/he was told by staff that the air mattress is set by weight. Further, the surveyor observed the air mattress setting at 200 lbs., on static. Subsequent surveyor observations on the following dates and times revealed the air mattress was set to 200 lbs. and static: -9/26/2023 at 8:43 AM -9/27/2023 at approximately 9:30 AM -9/28/2023 at 10:32 AM During a surveyor interview on 9/28/2023 at 10:41 AM with Licensed Practical Nurse, Staff G, he was unable to explain what static meant for the air mattress setting and he was not aware the resident felt uncomfortable on his/her air mattress. 3. Record review for Resident ID #73 revealed s/he was re-admitted to the facility in July of 2021 with diagnoses including, but not limited to, stroke, hemiplegia (paralysis that affects the ability to move the lower portion of the body) and hemiparesis (weakness to one side of the body) affecting the left side. Record review revealed an order dated 6/9/2023 for a specialty air mattress to check setting and function every shift. Record review revealed a care plan with a focus for being at risk for skin breakdown due to decreased mobility and incontinence, with a revised intervention date of 5/12/2021 to include a specialty air mattress check setting and function every shift. The care plan failed to reveal evidence of a setting for the air mattress. Surveyor observation on 9/28/2023 at 10:35 AM, revealed the resident was lying in bed with the air mattress setting on 200 lbs., static. Further observation revealed a sticker affixed to the air mattress pump with writing that read alt/200. Subsequent surveyor observation on 9/28/2023 at 10:47 AM revealed the air mattress was set to 200 lbs., on static. During a surveyor interview at the time of the above-mentioned observation with Staff B, she acknowledged the air mattress was set at 200 lbs., static and that the sticker affixed to the air mattress pump read alt/200. Further, she revealed that the Staff F, sets the mattress settings. 4. Record review revealed Resident ID #102 was re-admitted to the facility in April of 2023 with diagnoses including, but not limited to, left femur fracture and stroke. Record review revealed an order dated 5/10/2023 for a specialty air mattress, check setting and function every shift. Record review revealed a care plan with a focus for being at risk for skin breakdown due to decreased mobility and occasional bladder incontinence, with a revised intervention date of 5/16/2023 to include, a pressure reducing alternating air mattress monitor settings every shift. The care plan failed to reveal evidence of a setting for the air mattress. Surveyor observation on 9/25/2023 at 8:44 AM revealed the resident lying in bed with the air mattress setting observed on static. Further observation revealed a sticker affixed to the air mattress pump with writing that read alt/150. During subsequent surveyor observations on the following dates and times revealed the air mattress was set to 150 lbs., static: -9/26/2023 at 9:06 AM -9/26/2023 at 2:17 PM -9/27/2023 at 9:24 AM -9/28/2023 at 8:51 AM -9/28/2023 at 9:25 AM During a surveyor interview on 9/28/2023 at 9:25 AM with Staff G, he acknowledged the air mattress setting was on static. Further, he revealed that he checks the air mattress to make sure that the mattress is plugged in and that the green light is on. Additionally, he could not explain why the air mattress was set to static. During a surveyor interview on 9/28/2023 at 10:51 AM with the DNS, she revealed that she would expect the air mattress orders to include a specific setting. Further, she revealed the air mattresses should be set to alternating pressure, unless they are providing care to the resident.

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 F0676 (Tag F0676)

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 the necessary care and services to ensure that a resident's abilities in activities of daily living (ADL's) do not diminish unless circumstances of the individual's clinical condition demonstrate that such a diminution was unavoidable, relative to transfer, ambulation, toileting and incontinence care for 1 of 4 residents reviewed, Resident ID# 9. Findings are as follows: Record review revealed the resident was admitted to the facility in April of 2023 with diagnoses including, but not limited to, schizoaffective disorder (a mental health condition), adult failure to thrive (FTT), neuroleptic induced parkinsonism (parkinsonism caused by antipsychotic, neuroleptic, medication) and major depressive disorder. Record review of the Annual Minimum Data Set Assessment (MDS), dated [DATE], revealed s/he required supervision assistance of one staff member for bed mobility, transfer, and supervision with set up for ambulation. Additionally, review revealed s/he experienced occasional bowel incontinence. Further review revealed s/he had a Brief Interview for Mental Status score of 15 out of 15, indicating the resident has intact cognition. Record review of the Quarterly MDS, dated [DATE], revealed s/he now requires extensive assistance of two or more staff members for transfers and bed mobility. Additionally, s/he had not ambulated in the 7-day look back period. Lastly, s/he now requires extensive assistance of two or more staff members for personal hygiene, toileting, and always experiences bowel incontinence. This indicates the resident experienced a significant change ( a major decline or improvement in the resident's status that will not normally resolve itself without interventions by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status and requires interdisciplinary review or revision of the care plan, or both). Record review of a progress note dated 7/13/2023 at 2:50 PM states in part, Quarterly MDS completed .[s/he] requires extensive assistance with ADL's, toileting, and transfers. [s/he] is non ambulatory. [s/he] is incontinent of B&B [bowel and bladder]. [resident] has not had any significant change since [his/her] last assessment. Care plan reviewed and updated. Further review of the record failed to reveal evidence that a significant change MDS assessment (required when a resident experiences a consistent pattern of changes, with either two or more areas of decline or two or more areas of improvement, from baseline) was completed for Resident ID# 9. Additional record review revealed a care plan dated 4/10/2023 with revision a date of 7/23/2023, which indicates the resident has ADL deficit related to generalized weakness due to FTT. Further review of the care plan failed to reveal evidence of new interventions being implemented after the MDS dated [DATE] which revealed a decline in two or more care areas. During a surveyor interview on 9/27/2023 at 3:24 PM with Registered Nurse, Staff B, she acknowledged that the resident has an increased need for staff assistance with ADL's. She further revealed that the resident was previously able to ambulate independently. During a surveyor interview on 9/28/2023 at 2:07 PM with the MDS Coordinator, she acknowledged that decline in the resident's ADL's warranted a significant change assessment, and it was not completed. Review of a facility policy titled; Screens states in part, To identify those patients/residents who would benefit from skilled rehabilitation intervention .all patients/residents will be screened annually or as needed, and with a documented change in condition . Record review of a physical therapy Discharge summary dated [DATE] revealed the resident received physical therapy services from 5/17/2023 through 5/31/2023. Further review reveals that the resident was discharged from services ambulating up to 150 feet with supervision and the use of an assistive device. During a surveyor interview with the Rehabilitation Director, she was unable to provide evidence that a rehabilitation screen had been completed for Resident ID # 9's change in condition per policy. During a surveyor interview on 9/28/2023 at approximately 2:23 PM with the Director of Nursing, she acknowledged that the resident had a decline in ADL's. Additionally, she was unable to provide evidence that the resident was provided with the necessary care and services to ensure that a resident's abilities in activities of daily living were maintained. Lastly, she was unable to explain why a significant change assessment was not completed.

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

ADL Care (Tag F0677)

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 the necessary services to a resident who is unable to carry out activities of daily living (ADLs), relative to showers for 2 of 4 residents reviewed, Resident ID #s 35 and 73. Findings are as follows: 1. Record review for Resident ID #35 revealed s/he was readmitted to the facility in December of 2022 with medical diagnoses including, but not limited to, spinal stenosis (the narrowing of the spine which puts pressure on the spinal cord and nerves and can cause pain) and difficulty walking. Record review of an Annual Minimum Data Set (MDS) assessment dated [DATE] revealed that it is very important for him/her to choose between a tub bath, shower, bed bath, or sponge bath. Record review of a Quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Additionally, s/he is documented as requiring the physical assistance of one staff member for bathing. Record review of a care plan revised on 6/6/2023 revealed s/he has a deficit in performing ADL's related to general weakness with interventions including, but not limited to, one staff member for assistance with ADL's. During a surveyor observation of the 3rd floor unit on 9/27/2023 at 9:42 AM, the resident was overheard by a surveyor requesting assistance from staff for a shower, because it had been a while since s/he last received one. During a surveyor interview on 9/27/2023 at 10:52 AM, with Resident ID #35, s/he indicated that staff do not offer him/her a shower and indicated s/he refused only once. Additionally, s/he indicated his/her last shower was almost 2 months ago. Record review of the August and September 2023 nursing assistant (NA) documentation for bathing, failed to revealed the resident's last documented shower was on 8/10/2023, indicating s/he had not received a shower in approximately 7 weeks. 2. Record review for Resident ID #73 revealed s/he was readmitted to the facility in July of 2021 with diagnoses including, but not limited to, stroke, hemiplegia and hemiparesis affecting the left side (weakness and paralysis on one side of the body). Record review of an Annual MDS assessment dated [DATE] revealed that it is somewhat important for him/her to choose between a tub bath, shower, bed bath, or sponge bath. Record review of a Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating intact cognition. Additionally, s/he is documented as requiring total assistance of one staff member for bathing. Record review of the September 2023 Treatment Administration Record revealed a physician's order with a start date of 7/18/2023 indicating the resident is scheduled to receive a shower every Tuesday on the 7:00 AM - 3:00 PM shift. During a surveyor interview on 9/28/2023 at 8:47 AM with the resident, s/he indicated that s/he needs a shower because s/he has not received one in a few weeks. When the surveyor asked if it was the resident's preference to skip showers, s/he stated, they don't offer. Review of the September 2023 document for bathing failed to reveal evidence that the resident received a shower from 9/1/2023 - 9/27/2023. Further record review of the July through September 2023 NA documentation, failed to revealed the only shower documented was on 8/25/2023. Additional record review failed to reveal evidence that s/he refused any showers. During a surveyor interview on 9/27/2023 at 1:33 PM with Certified Medication Technician (CMT), Staff H, she indicated that although she provided care to Resident ID #73 on 9/26/2023 during the 7:00 AM-3:00 PM shift, she did not provide him/her with a shower as ordered. During a surveyor interview on 9/28/2023 at 8:57 AM, with Registered Nurse, Staff B, she indicated that she has never observed the resident receive a shower and she was unable to provide evidence that s/he had refused a shower. Additionally, she revealed that she would have expected that on 9/26/2023 the assigned staff member would have assisted the resident with a shower. During a surveyor interview on 9/28/2023 at 9:29 AM with the Director of Nursing Services, she indicated that her expectation is for staff to provide residents with a shower on the day it is scheduled and to document any refusals.

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 ensure that food is stored, served, and distributed, in accordance with profession...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored, served, and distributed, in accordance with professional standards for food service safety, relative to the main kitchen and for 3 of 3 unit kitchenettes observed. Findings are as follows: 1. The Rhode Island Food Code 2018 Edition 2-402.11 states in part, .food employees shall wear hair restraints, beard restraints that are designed and worn to effectively keep their hair from contacting exposed food . During surveyor observations in the main kitchen revealed the following: -9/25/2023 at approximately 8:40 AM dietary staff, Staff M and N, were observed without beard restraints. -9/25/2023 at approximately 2:30 PM, dietary staff, Staff O, was observed without a beard restraint. -9/26/2023 at approximately 11:20 AM dietary staff, Staff M and N were observed without beard restraints. -9/27/2023 at approximately 1:15 PM, dietary staff, Staff M, was observed without a beard restraint. -9/27/2023 at approximately 3:30 PM, dietary staff, Staff O, was observed without a beard restraint. 2. The Rhode Island Food Code 2018 Edition 3-602.11 Food Labels, states in part, .Label Information shall include .the common name of the FOOD . Surveyor observations on 9/27/2023 at approximately 9:55 AM of the nursing unit kitchenettes revealed the following: -2nd floor kitchenette with 5 plastic containers dated without a label identifying the brown pudding like substance and 3 containers dated without a label identifying the yellow pureed substance. -3rd floor kitchenette with 6 plastic containers dated without a label identifying the brown pudding like substance and 4 containers dated without a label identifying the white/yellow substance. -4th floor kitchenette with 10 plastic containers dated without a label identifying the brown pudding like substance and 2 containers dated without a label identifying the white/yellow substance. During a surveyor interview on 9/28/2023 at approximately 1:15 PM with the Food Service Director, he acknowledged beard restraints were not in use during the above surveyor observations, and the products on the nursing unit kitchenettes failed to have labels to identify the product inside the containers.

Aug 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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

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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 meet professional standards of quality relative to following physician's orders for 1 of 1 resident reviewed, Resident ID #2. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Review of the resident's record revealed s/he was admitted to the facility in March 2023 with diagnoses including, but not limited to, heart failure and shortness of breath. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 12 out of 15 indicating that his/her cognition is moderately impaired. Record review revealed the following physician's orders: - 3/17/2023 -Ted Stocking (socks to help prevent blood clots and swelling in the legs) on during the day and off at night for history of pulmonary embolism (condition in which one or more arteries in the lungs is/are blocked by a blood clots) every shift. - 3/17/2023- Offload Heels every shift as tolerated for skin integrity. - 6/16/2023- Compression sleeve (a sleeve that is used to protect the upper extremities from abrasions, bruises, snags, and tears throughout the day and to aid in relieving the discomfort associated with swelling) to right upper extremity related to edema (swelling) every shift. During surveyor observations on 8/1/2023 at 12:40 PM and at 2:00 PM the resident was observed in bed with a swollen right arm and swollen feet. His/her heels were observed to be lying directly on the bed and not offloaded. Further observation failed to reveal evidence that the sleeve to his/her right upper extremity was applied or that the [NAME] stockings were on as ordered. During a surveyor interview on 8/1/2023 at 2:00 PM with the resident s/he acknowledged that s/he was not wearing the compression sleeve or [NAME] stockings. The resident stated I don't think the staff knows they are supposed to apply the [NAME] stocking or the compression sleeve. During a surveyor interview on 8/1/2023 at 2:10 PM with Registered Nurse, Staff A, following the interview with the resident, she acknowledged the resident's heels were not offloaded, that s/he was not wearing the compression sleeve to the right upper extremity and that s/he was not wearing the [NAME] stockings. Additionally, Staff A was unable to explain why the above-mentioned orders were not completed. During a surveyor interview on 8/1/2023 at approximately 2:30 PM with the Director of Nursing Services in the presence of the Administrator, she acknowledged that the compression sleeve, the [NAME] stockings, and the offloading of the resident's heels were included in the resident's orders. However, she was unable to explain why the orders were not completed as evidenced by the surveyor observations on 8/1/2023 at 12:40 PM and 2:00 PM.

CONCERN (D) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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

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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 maintain medical records that are accurately documented in accordance with professional standards and practices for 1 of 1 resident reviewed for inaccurate documentation, relative to the use of a compression sleeve, [NAME] stockings and offloading the resident's heels, Resident ID #2. Findings are as follows: Review of the resident's record revealed s/he was admitted to the facility in March 2023 with diagnoses including, but not limited to, heart failure and shortness of breath. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 12 out of 15 indicating that his/her cognition is moderately impaired. Record review revealed the following physician's orders: - 3/17/2023 -Ted Stocking (socks to help prevent blood clots and swelling in the legs) on during the day and off at night for history of pulmonary embolism (condition in which one or more arteries in the lungs is/are blocked by a blood clots) every shift. - 3/17/2023- Offload Heels every shift as tolerated for skin integrity. - 6/16/2023- Compression sleeve (a sleeve that is used to protect the upper extremities from abrasions, bruises, snags, and tears throughout the day and to aid in relieving the discomfort associated with swelling) to right upper extremity related to edema (swelling) every shift. During surveyor observations on 8/1/2023 at 12:40 PM and at 2:00 PM the resident was observed in bed with a swollen right arm and swollen feet. His/her heels were observed to be lying directly on the bed and not offloaded. Further observation failed to reveal evidence that the sleeve to his/her right upper extremity was applied or that the [NAME] stockings were on as ordered. Record review of the August 2023 Medication Administration Record (MAR) reviewed on 8/1/2023 at approximately 1:40 PM revealed that Registered Nurse, Staff A, had signed off on the above-mentioned orders indicating that the TED stockings and the compression sleeve were applied, and that his/her heels were offloaded. During a surveyor interview on 8/1/2023 at 2:10 PM with Registered Nurse, Staff A she acknowledged the resident's heels were not offloaded, that s/he was not wearing the compression sleeve to the right upper extremity and that s/he was not wearing the [NAME] stockings. Additionally, Staff A was unable to explain why she signed off on the MAR that these orders were completed when they were not. During a surveyor interview on 8/1/2023 at approximately 2:30 PM with the Director of Nursing Services in the presence of the Administrator, she acknowledged that the orders were signed off by Staff A. Additionally, she was unable to explain why the documentation in the resident's medical record was inaccurately documented.

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Based on surveyor observations, record review and resident and staff interview, it has been determined that the facility failed to ensure a sanitary environment to help prevent the transmission of inf...

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Based on surveyor observations, record review and resident and staff interview, it has been determined that the facility failed to ensure a sanitary environment to help prevent the transmission of infections for 1 of 1 residents observed with an uncovered open wound that was draining onto the floor of the facility, Resident ID #7. Findings are as follows: Record review of the facility policy titled, General Infection Control Nursing Policies, states in part, .It is the policy of this facility .to minimize the potential for infection in residents, staff and visitors .Resident rooms will be clean .All resident common areas will be maintained .clean .and will be free of obvious hazards . Record review revealed that the resident was readmitted to the facility in November of 2022. S/he has medical diagnoses that include but are not limited to, Alzheimer's disease, pressure-induced deep tissue damage of left heel, and delusional disorders. Further record review revealed a care plan initiated on 3/24/2022 which indicates that the resident has a left heel and dorsal (top of the foot/area facing upwards when standing upright) foot pressure wound. Additional record review revealed the following physician orders which states in part: 12/20/2022 - Left heel and anterior ankle: Cleanse with NS [normal saline], apply Santyl [a prescription medicine that removes dead tissue from wounds so they can start to heal] f/b [followed by] moist gauze to wound bed only and kling [gauze dressing wrap] .every other day 12/22/2022 - Left Great Toe .wrap entire foot .every other day . During a continuous surveyor observation on 1/19/2023 from approximately 9:12 AM to 11:09 AM, revealed the resident to be seated at a table in the unit dining room with his/her bare left foot, that has an open wound on its heel, touching the floor. Additionally, the resident's left foot appeared swollen with dry skin. A dry gauze was observed partially covering a wound to the top of the resident's left foot and the resident's left lower pant leg appeared wet. Additionally, clear liquid and/or drainage was observed on the floor under and around his/her foot. The resident was seated at a table alone however there were approximately 6 other residents in the dining room seated at other tables and one resident who was observed walking/wandering around the dining room. Furthermore, the liquid and/or drainage from the wound on the resident's left heel wound, remained on the floor for the duration of the observation, approximately 1 hour and 57 minutes. Additional record review revealed the following progress notes which state in part: On 10/13/2022 at 6:22 PM .Member often takes off [his/her] dressing, removes foot coverings and ambulates around [his/her] room .bathroom and the unit with a bare left foot . On 1/13/2023 at 6:45 AM .Lower left leg and foot are red and swollen, with a foul odor and yellow drainage seeping out of sock . On 1/16/2023 at 6:50 AM .Residents LLE [left lower extremity] is weepy, with bright green/yellow/blue tinged drainage . On 1/16/2023 at 12:23 PM .worsening condition of residents wounds on left foot .NP [Nurse Practitioner] gave .orders for .Wound culture . On 1/17/2023 at 4:27 PM .left foot .gauze wrap was noted to be saturated with clear liquid . On 1/17/2023 at 9:38 PM .Resident unwrapped dressings .and threw it onto floor in hallway . On 1/18/2023 at 6:35 AM .ABD [abdominal bandage, an extra thick dressing designed to care for draining wounds] pad to LLE drenched in thick, bright green/yellow drainage . During a subsequent surveyor observation on 1/19/2023 at 11:10 AM, revealed the resident transferred him/herself independently from the dining table chair into his/her wheelchair. Additionally, the wheelchair did not have footrests in place and s/he was able to self-propel in the wheelchair from the dining room to his/her bedroom. Throughout this observation the open wound on the resident's left heel was touching the floor. During a follow up surveyor observation on 1/19/2023 at approximately 11:25 AM the resident was observed to be assisted with toileting by Licensed Practical Nurse (LPN), Staff A, in the unit bathroom. The open wound on the heel of the resident's left foot continued to touch the floor when the resident stood from the wheelchair to transfer to the toilet. During a follow up surveyor observation on 1/19/2023 at 1:10 PM the resident was observed in his/her room seated in a wheelchair with the open wound on the heel of his/her left foot touching the floor. Additionally, yellow tinged liquid and/or drainage was observed on the floor under his/her foot approximately 1 - 2 inches in diameter surrounding the resident's foot on the floor. Furthermore, the liquid color on the floor was not the same color as the drinks on his/her lunch tray. During a surveyor interview with LPN, Staff B, on 1/19/2023 immediately following the above-mentioned observation, she acknowledged the resident's open wound was touching the floor and that there was liquid and/or drainage on the floor surrounding and under the resident's foot. Additionally, she acknowledged that the liquid and/or drainage color was not the same color of the drinks on the resident's lunch tray. Furthermore, she indicated that she would have someone clean the liquid and/or drainage from the floor. During a surveyor interview with Infection Control Nurse, Staff C, on 1/19/2023 at approximately 1:20 PM, she indicated that she would expect the drainage from the resident's open wound to be contained and not on the floor of the facility. During a surveyor interview with the resident on 1/19/2023 at 11:15 AM, s/he indicated that s/he did not want the dressing on because it was tight. During a surveyor interview with the Director of Nursing Services on at 11:45 AM, she revealed that the resident refuses dressings to his/her left heel pressure wound. Additionally, she indicated that the facility has tried different treatments which the resident refused however, she was unable to state which treatments were offered. Additionally, she was unable to provide evidence that other interventions to contain the drainage of the resident's pressure wound to his/her left heel were offered. Furthermore, she was unable to provide evidence that the facility ensured a sanitary environment to help prevent the transmission of infection relative to the drainage of the resident's left heel pressure wound.

Nov 2022 6 deficiencies 3 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Quality of Care (Tag F0684)

A resident was harmed · This affected 1 resident

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, for 1 of 1 residents with limited range of motion (ROM) who sustained an arm fracture during routine care, Resident ID #5. Findings are as follows: Record review revealed the resident was admitted to the facility in June of 2021 with diagnoses including, but not limited to, non-traumatic intracerebral hemorrhage (stroke), hemiplegia (paralysis affecting one side of the body) affecting left nondominant side, and contracture of muscle, left and right lower leg. Review of a discharge summary from Physical Therapy (PT) dated 6/30/2021 stated in part, .Pt [patient] presenting with BUE [bilateral upper extremity] and LE [lower extremity] contracture, right side> [greater than] left side, pt's family requesting a evaluation for training for ROM to prevent further contracture . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severe cognitive impairment. Further review of the MDS quarterly assessments dated 1/5/2022, 4/5/2022, 10/4/2022, and an annual MDS assessment dated [DATE] revealed the resident had impairments on both sides of the upper and lower extremities relating to functional range of motion. The MDS assessments on the above-mentioned dates further revealed that the resident required extensive assistance of two or more persons relative to bed mobility (including turning side to side while in bed). Review of a care plan initiated 6/4/2021 revealed .has contracture of bilateral lower extremities. Further review of the care plan failed to identify any impairment to the upper extremities, specifically the left arm. Review of a progress note dated, 10/29/2022 at 9:30 AM, stated in part, .left arm became tight against [his/her] T-shirt and CNA [Certified Nursing Assistant] reported that [his/her] left arm made a popping sound .xray ordered, which showed a left humerus [bone of upper arm] fracture .Patient transferred to [hospital] for further evaluation . Review of the hospital note dated 10/29/2022, states in part, .[s/he] was combative with staff while they were attempting to change [him/her] when they think [s/he] dislocated or broke [his/her] left shoulder .patient complains of extreme pain .is contracted on [his/her] left side .noted to have hemi-paralysis to [his/her] left side which [s/he] is noted to be a baseline deficit from an old stroke . Further review of the of the X-ray results from the hospital on [DATE] states in part, .mildly displaced spiral fracture [a fracture which is caused by a rotational, or twisting, force] . During a surveyor interview with Nursing Assistant (NA), Staff D, on 11/1/2022 at 1:22 PM, she acknowledged she was the person providing care for the resident when his/her arm broke. She revealed his/her left arm has been contracted since the resident was admitted . She revealed she usually dresses the bad arm (contracted left arm) first and then the right arm. Additionally, she revealed the resident usually requires one staff member for assistance with dressing but requires a two person assist if s/he becomes resistive or combative while receiving care. Additionally, she indicated that the resident requires two staff members for assistance with bed mobility. She acknowledged on the day the resident broke his/her arm; s/he was the only one providing care. She further revealed the resident was being combative while she was attempting to roll the resident (by herself) towards her to finish putting on a long sleeve shirt. She indicted that when she pulled on the shirt to get the sleeve over the resident's right arm is when she heard a pop from the left arm. Staff D revealed she would have asked for assistance while providing care on that day but revealed there was not enough staff available to help, and she was rushing to have the resident's care completed prior to his/her family members visiting that morning. She then indicated she would have done things differently that day considering the resident was combative and she should have asked for assistance from another staff member when rolling the resident. During a surveyor interview with NA, Staff E, on 11/2/2022 at 11:11 AM, she revealed the resident is difficult to turn with only one person. She further revealed his/her left arm is contracted making it difficult to put a shirt on. Additionally, she revealed while dressing the resident, you should dress the left arm first. During a surveyor interview with NA, Staff F, on 11/2/2022 at 11:22 AM, she indicated the resident is supposed to be two people relative to his/her daily care. She further revealed that Staff D approached her after hearing the popping noise and said to her I snapped this [resident's] arm. Staff F accompanied Staff D to the resident's room, and Staff F acknowledged she observed the resident's right arm was fully through the sleeve of the shirt, but the left arm (more contracted arm) was not in the sleeve - with the shirt only resting over the resident's shoulder. During an interview with the Administrator and the Director of Nurses on 11/10/2022 at approximately 3:00 PM they were unable to provide evidence that Resident ID #5 was provided care in accordance with professional standards of practice and his/her comprehensive person-centered care plan.

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Deficiency F0726 (Tag F0726)

A resident was harmed · This affected 1 resident

**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 nursing staff has the app...

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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 nursing staff has the appropriate competencies and skill sets to provide nursing and related services to assure resident safety as identified through resident assessments and described in the plan of care for Resident ID #5. Findings are as follows: Record review revealed the resident was readmitted to the facility in December of 2021 with diagnoses including, but not limited to, non-traumatic intracerebral hemorrhage (stroke), hemiplegia (paralysis affecting one side of the body) affecting left non-dominant side, and contracture of muscle, left and right lower leg. Review of a Minimum Data Set (MDS) quarterly assessments dated 1/5/2022, 4/5/2022, 10/4/2022, and an annual MDS assessment dated [DATE] revealed the resident had impairments on both sides of their upper (shoulder, elbow, wrist, hand) and lower (hip, knee, ankle, foot) extremities relating to functional range of motion. The MDS assessments on the above-mentioned dates further revealed that the resident required extensive assistance of two or more persons relative to bed mobility (including turning side to side and body positioning while in bed). Further record review revealed a nursing progress note dated, 10/29/2022 at 9:30 AM, states in part, .[his/her] left arm became tight against [his/her] T-shirt and CNA [Certified Nursing Assistant, Staff D] reported that [the resident's] left arm made a popping sound .xray ordered, which showed a left humerus [bone of upper arm] fracture . Additional record review of the radiology interpretation document dated 10/29/2022 of the left shoulder stated in part, .mildly displaced spiral fracture [occurs due to a rotational, or twisting, force] . During a surveyor interview with Staff D, on 11/1/2022 at 1:22 PM, she acknowledged she was the person providing care for the resident when his/her arm broke. She revealed his/her left arm has been contracted since the resident was admitted . Additionally, she revealed the resident usually requires one staff member for assistance with dressing but requires a two person assist if s/he becomes resistive or combative while receiving care. Additionally, she indicated that the resident requires two staff members for assistance with bed mobility. She acknowledged on the day the resident broke his/her arm; s/he was the only one providing care. She further revealed the resident was being combative while she was attempting to roll the resident (by herself) towards her to finish putting on a long sleeve shirt. She indicted that when she pulled on the shirt to get the sleeve over the resident's right arm is when she heard a pop from the left arm. Staff D revealed she would have asked for assistance while providing care on that day but revealed there was not enough staff available to help, and she was rushing to have the resident's care completed prior to his/her family members visiting that morning. She then indicated she would have done things differently that day considering the resident was combative and she should have asked for assistance from another staff member when rolling the resident. Record review of Staff D's personnel file failed to reveal evidence of the appropriate competencies and skill sets to provide nursing and related services to assure resident safety as identified through resident assessment and described in the plan of care relative to limited range of motion. During a surveyor interview with Nursing Assistant, Staff J, on 11/1/2022 at 4:25 PM, she revealed the resident requires a 2 person assist with repositioning while in bed. She further revealed that the resident requires a 2 person assist with care if s/he is combative. During an additional surveyor interview with Licensed Practial Nurse, Staff K, on 11/1/2022 at 4:20 PM, she revealed she has heard the resident yelling, especially during care, and most of the time the resident requires a 2 person assist with care and repositioning, due to both upper and lower extremity impairments. During an interview with the Staff Development Coordinator on 11/3/2022 at 2:38 PM, she was unable to provide evidence that in-services relative to limited range of motion were provided to nursing staff. During a surveyor interview with the Director of Nursing on 11/4/2022 at approximately 2:00 PM, she was unable to provide evidence that Staff D has the appropriate competencies and skill sets to provide nursing and related services to ensure resident safety as identified through resident assessments as described in the plan of care relative to limited range of motion.

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 F0838 (Tag F0838)

A resident was harmed · This affected multiple residents

Based on record review and staff interview, it has been determined that the facility failed to identify the care required by the resident population considering the types of disease, conditions, physi...

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Based on record review and staff interview, it has been determined that the facility failed to identify the care required by the resident population considering the types of disease, conditions, physical and cognitive disabilities. Additionally, the facility failed to ensure that staff has competencies that are necessary to provide the level and types of care needed for the resident population at risk and/or have limited range of motion (ROM). Furthermore, the facility failed to have necessary resources including a dementia care coordinator. Findings are as follows: Review of the Facility Assessment Annual Review dated 2/20/2022, reveals in the section titled, Part 1: Our Resident Profile, which indicates that the second floor is a secured dementia unit, which has a 60-bed capacity (average daily census is 59-60 residents). The Facility Assessment also indicates that Alzheimer's disease, stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts. In either case, parts of the brain become damaged or die. A stroke can cause lasting brain damage and/or long-term disability), hemiparesis (paralysis on one side of the body), and hemiplegia (another term for hemiparesis) are common resident diagnoses. Alzheimer's disease, stroke, hemiparesis, and hemiplegia are all diagnosis that have a strong potential for a physical impairment relating to ROM or are diagnosis that are directly related to ROM. Further record review failed to reveal evidence that the facility developed or implemented a plan for residents who are at risk and/or have a diagnosis of limited ROM. Additionally, the Facility Assessment reveals under the section titled, Part 3: Facility Resource Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies indicates Staff type .Dementia care coordinator . and .Staffing plan .Dementia Care Coordinator -40 [hours/week] .Staff training/education and competencies . During the initial interview with the Director of Nursing (DON) on 11/1/2022 at 8:25 AM, she revealed that all residents residing on the second-floor secured dementia unit have a diagnosis of dementia. During a surveyor interview with the Administrator and the DON on 11/4/2022 at 2:30 PM, they acknowledged that limited ROM was not included in the facility assessment or that there was a plan implemented to address the resident's requiring assistance with limited ROM. The DON revealed the facility has not had a Dementia Care Coordinator since 2020.

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

Comprehensive Care Plan (Tag F0656)

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 implement a comprehensive person-centered care plan for 2 of 2 residents reviewed r...

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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to implement a comprehensive person-centered care plan for 2 of 2 residents reviewed relative to mood and behavior, Resident ID's #6 and 12. Findings are as follows: 1. Record review for Resident ID #6 revealed s/he was admitted to the facility in July of 2021 with diagnoses including, but not limited to cerebral infarction (stroke), mood disorder, post-traumatic stress disorder (PTSD), and suicidal ideation. Record review revealed a care plan initiated on 4/23/2021 and revised on 7/9/2021 for, .is at risk for changes in mood state secondary to diagnosis of mood disorder. History of PTSD, history of exhibiting racial behaviors towards staff . Further review of the care plan revealed an intervention dated 7/21/2022 which indicates, .stop sign across doorway to prevent uninvited visitors . Additional, record review revealed a care plan dated 7/21/2022 for .was involved in a resident to resident altercation . This care plan has an intervention dated 7/21/2022 which indicates, .Stop sign across doorway to prevent uninvited visitors . During surveyor observations on 11/1/2022 at 1:57 PM and 11/3/2022 at 10:50 AM revealed the resident lying in his/her bed with no stop sign banner affixed across the doorway. During a surveyor interview with Nursing Assistant (NA), Staff B, on 11/3/2022 at 11:32 AM, she revealed she has been assigned to provide care to Resident ID #6 several times and has never observed a stop sign banner across the resident's doorway. During a surveyor interview with the resident on 11/3/2022 at 11:39 AM, s/he acknowledged there was no stop sign across the doorway and could not recall the last time the sign was there. During the above interview, Resident ID #6 was pointing at Resident ID #12 who was observed to be walking by Resident ID #6's room several times. Resident ID #6 revealed that Resident ID# 12 entered his/her room previously and ate his/her sandwich. S/He further revealed s/he then threw a cup of coffee at Resident ID #12. 2. Record review for Resident ID #12 revealed s/he was admitted to the facility in April of 2022 with diagnoses including, but not limited to, Alzheimer's disease and vascular dementia. Record review revealed a care plan initiated on 5/6/2022 for, Behavior Problems exhibited by: wandering on unit into other peoples space. This care plan has an intervention dated 6/14/2022 which indicates .Stop sign placed on the room [s/he] gravitates to . Additional, record review revealed a care plan initiated on 7/21/2022 and revised on 8/24/2022 for .[Resident] was involved in a resident to resident. 8/23: resident was scratched by another resident . This care plan has intervention dated 7/21/2022 which indicates Stop sign placed on other resident's doorway . Further record review revealed a care plan dated 8/23/2022 for .[Resident] is prone to aggression and intrusive behaviors . During multiple surveyor observations on 11/3/2022 through 11/4/2022 Resident ID #12 was observed wandering the unit hallways. During an interview with NA, Staff C, on 11/3/2022 at 11:48 AM, she revealed she usually works on this unit and was unaware that Resident ID #6 has a care plan intervention for a stop sign across the doorway. She further revealed she has never observed a stop sign banner across the doorway. During a surveyor interview with a Licensed Practical Nurse, Staff A, on 11/3/2022 at 11:28 AM, she acknowledged there was not a stop sign across Resident ID #6's doorway and could not recall the last time there was one. She acknowledged that Resident ID #12 wanders the unit and has entered the room of Resident ID #6 in the past.

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 F0688 (Tag F0688)

Could have caused harm · This affected multiple residents

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents with limited range of motion (ROM) receive appropriate treatment and services, to increase range of motion and to prevent further decrease in range of motion for 2 of 3 residents reviewed for limited mobility, Residents ID #'s 6, and 13. Findings are as follows: 1. Record review for Resident ID #6 revealed s/he was admitted to the facility in July of 2021 with diagnoses including, but not limited to, hemiplegia and hemiparesis (paralysis on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, contracture of muscle (unspecified site), and contracture (left knee). Record review revealed a quarterly Minimum Data Set assessment dated [DATE] that indicated the resident has an impairment on one side of his/her upper and lower extremities. Review of a care plan initiated on 2/16/2021, and revised on 8/31/2022, revealed a focus area, [S/he] has contracture of bilateral knees and left arm. with an intervention revised on 1/21/2022, for Passive/ active ROM as ordered. Further record review failed to reveal an order for Passive/ active ROM relative to the contracture of the knees or left arm. Record review of the Treatment Administration Record (TAR) failed to reveal evidence that passive/ active ROM has been provided to the resident. During a surveyor observation on 11/3/2022 at 11:41 AM revealed both of the resident's left upper and lower extremities were contracted. During a surveyor interview with the resident during the observation, s/he revealed that s/he has not been receiving passive/ active ROM to his/her left upper and lower extremities. The resident further revealed that when s/he asks staff for assistance with ROM exercises, the staff responds, We don't have therapy for you. During a surveyor interview with Nursing Assistant, Staff C, on 11/3/2022 at 11:47 AM she revealed she is a full-time employee of 3 years. She further revealed that she was assigned to care for the resident today. Additionally, she revealed that she has provided care to the resident on several occasions and that she has never performed ROM exercises with the resident. She revealed the resident cannot move his/her left arm and s/he wears a splint to the left hand. She further indicated the resident has pain to the left arm and therefore she doesn't touch it. During a surveyor interview with Licensed Practical Nurse, Staff A, on 11/3/2022 at 11:28 AM, she acknowledged the resident does not have an order for ROM in place. Additionally, she was unable to provide evidence that the resident was provided or was offered ROM exercises. 2. Record review for Resident ID #13 revealed s/he was readmitted to the facility in August of 2022 with diagnoses including, but not limited to, wedge compression fracture of thoracic vertebra (bones in the middle section of spine), erythromelalgia (neurovascular pain disorder particularly affecting the hands and feet), and pain in right hand. Review of the Minimum Data Set assessment dated [DATE] revealed a BIMS score of 14 out of 15, indicating the resident is cognitively intact. Record review revealed a quarterly MDS assessment dated [DATE] under Functional Limitation in Range of Motion, that indicated the resident has an impairment on one side of his/her upper extremity. Additionally, review of a care plan initiated on 8/3/2022 revealed .has contracture of right hand. with an intervention for, Passive/ active ROM as tolerated. Record review failed to reveal evidence of an order for passive/active ROM relative to the contracture of the right hand. Further review of the October and November 2022 TARs failed to reveal evidence that passive/active ROM had been provided to the resident. During a surveyor observation on 11/4/2022 at approximately 1:00 PM, revealed the resident's right hand was contracted. During a surveyor interview with the resident during the observation, the resident revealed staff does not offer to assist him/her with ROM exercises. During a surveyor interview with a Nursing Assistant, Staff G, on 11/4/2022 at 1:05 PM, he revealed that he has not provided ROM for the resident and would only do so when instructed by the nurse. During a surveyor interview with the Occupational Therapist, Staff H, and the Director of Rehab on 11/4/2022 at 8:30 AM, they refer residents to the nursing staff when residents are discharged from therapy and nursing should provide active/passive ROM. During a surveyor interview with LPN, Staff I, on 11/4/2022 at 1:25 PM, she revealed nursing staff does not provide active/passive ROM. She stated, therapy does it. Additionally, Staff I revealed that nursing will only provide active/passive ROM if there is an order to do so. Staff I further revealed that the resident does not have an order for active/passive ROM. Staff I was unable to provide evidence that the resident was offered assistance with active/passive ROM or that s/he refused. During a surveyor interview with the Director of Nurses on 11/4/2022 at approximately 3:00 PM, she was unable to provide evidence that Resident ID #'s 6 and 13 receive appropriate treatment and services, to increase range of motion and to prevent further decrease in range of motion.

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 F0742 (Tag F0742)

Could have caused harm · This affected multiple residents

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

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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 display, or are diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1 of 5 residents assessed for mental and psychosocial well-being, Resident ID #5. Findings are as follows: Record review revealed the resident was admitted to the facility in June of 2021, and readmitted in December of 2021 with diagnoses including, but not limited to, non-traumatic intracerebral hemorrhage (stroke), hemiplegia (paralysis affecting one side of the body) affecting left non-dominant side, anxiety disorder, major depressive disorder, and encephalopathy (a disease of the brain that alters brain function or structure.) Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severe cognitive impairment. Review of the progress notes revealed the following: -12/7/2021: .Resident is alert and oriented to person with baseline agitation .continues with increased agitation, screaming at top lungs all day, pupils dilated, eyes bulging out of head, increased contractures, grinding [clenching] teeth .resident sent for geri-psych evaluation . -12/7/2021: .admitted .with DX [diagnosis] of psychological complain [complaint] and is at [NAME] [sic] psych . -12/29/2021: .Patient came back to the facility around 1:45pm .with admitting diagnosis of dementia with disturbance and depression . -12/30/2021: .Will make referral to psych. -1/12/2022: .on multiple psychotropic medications .followed by psych as needed . Review of the INITIAL Psychiatric Evaluation and Consultation document dated 7/17/2022 (approximately 7 months after readmission) revealed in part, .pt [patient] with chronic psych illness, stable on current regimen . Additionally, the consultation acknowledged the patient would benefit from continued behavioral health follow ups, and stated, .Will follow up in one month. Further review of the record failed to reveal evidence that another psychiatric consultation was completed. Review of the Treatment Administration Record (TAR) for November of 2022 revealed the resident was receiving the following medications relative to psychosocial health for anxiety and depression: -Sertraline 100 milligrams (MG) daily for depression -Quetiapine Fumarate 100 MG twice daily for anxiety Further record review of the TAR failed to reveal evidence that the resident was monitored for behaviors. During a surveyor interview with Licensed Practical Nurse, Staff A, on 11/2/2022 at 10:47 AM, she acknowledged yelling is a frequent behavior and revealed s/he has been yelling since his/her admission. During a surveyor interview with Nursing Assistant, Staff E, on 11/2/2022 at 11:11 AM, she revealed the resident screams and yells daily. During an additional surveyor interview with Licensed Practical Nurse, Staff L, on 11/2/2022 at 2:13 PM, she indicated that the resident screams 22 hours a day, from the minute s/he opens his/her eyes until s/he closes them. During a surveyor interview with the MDS Nurse on 11/3/2022 at 10:08 AM, she acknowledged she's heard the resident yelling continuously since s/he has been here. She further revealed the resident is difficult to redirect. She acknowledged the resident had no current order in place to monitor his/her behavior and that any resident on antipsychotics should have behavior monitoring orders in place.

Jul 2022 8 deficiencies

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional s...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to following physician orders and implementing physician orders when deemed necessary for 1 of 7 sample residents reviewed for skin conditions, Resident ID #76. Findings are as follows: Record review for Resident ID #76 revealed that the resident was admitted to the facility in November of 2020 with diagnoses including, but not limited to, peripheral vascular disease (progressive circulation disorder), type 2 diabetes mellitus, and morbid obesity. Record review of a Non-Pressure Wound Evaluation form dated 6/29/2022 revealed that the resident had a facility acquired skin tear to the coccyx measuring 1 centimeter (cm) in length by 1 cm in width and listed the Current Treatment .16a .c. start of treatment . Additional record review failed to reveal evidence of a physician's order for a treatment to the resident's coccyx from when it was identified on 6/29/2022 until the surveyor brought it to the Director of Nursing Services (DNS) attention on 7/7/2022. Further record review of a nursing progress note dated 7/7/2022 revealed that the Assistant Director of Nurses clarified the treatment orders for the buttocks and the coccyx after speaking with the surveyor. During a surveyor interview with the Director of Nurses on 7/11/2022 at approximately 2:45 PM she acknowledged that orders were not put into place when the area was identified and revealed that the treatment orders to the coccyx should have been put into place immediately.

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 surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 1 of 6 sample r...

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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 1 of 6 sample residents relative to anticoagulant medications (blood thinning medication used to prevent the formation of blood clots), Resident ID #122. Findings are as follows: Record review for the resident revealed that s/he was admitted to the facility in June of 2022 from an acute care hospital for short term services related to diagnoses, including but not limited to, history of falling and injury of the left ankle with subsequent surgical repair of the left ankle. Additional record review revealed a physician's order dated 6/7/2022 for anticoagulation medication, Enoxaparin Sodium 40 MG [milligrams]/0.4 ML [milliliters] prefilled syringe. Directions read in part, Inject .daily .until seen by orthopedics . Further record review revealed that the resident had a follow up appointment with the orthopedic physician on 6/17/2022 and on 6/28/2022. Record review of the resident's continuity of care forms following his/her orthopedic physician visits failed to provide evidence that the Enoxaparin was addressed per physician's order. Review of the Medication Administration Record (MAR) revealed that the resident received the medication from 6/8/2022 through 7/6/2022. During a surveyor interview with the Nurse Staff D on 7/6/2022 at approximately 2:54 PM, she was unable to provide evidence that the Enoxaparin order was addressed by the orthopedic physician during the resident's follow up appointments. Further record review revealed that the Enoxaparin order was addressed after the surveyor brought it to the facility's attention. The progress note dated 7/6/2022 3:29 PM read in part, Call placed to Ortho [Orthopedic] .returned call, d/c [discontinue] Lovenox [Enoxaparin]. During a surveyor interview with the Director of Nursing Services and the Assistant Director of Nursing Services on 7/06/2022 at approximately 3:03 PM, they were unable to provide evidence that the order for Enoxaparin was addressed at the orthopedic appointments per physician's order.

CONCERN (E)

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

Comprehensive Care Plan (Tag F0656)

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 develop and implement comprehensive person-centered care plans that include measura...

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Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to develop and implement comprehensive person-centered care plans that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents reviewed for falls, 1 of 4 residents reviewed for elopement, and 1 of 1 resident reviewed for oxygen use, Resident ID #'s 3, 329, and 580. Findings are as follows: 1. Record review revealed that Resident ID #3 was admitted to the facility in December of 2021 and has diagnoses including, but not limited to, congestive heart failure, hypertension, and Alzheimer's disease. Record review revealed the following physician's order: - Titrate 02 [oxygen] to maintain pulse ox [measurement of oxygenated hemoglobin in the body] greater than 92%. 02 at 2L [liters] via nasal canula every shift Surveyor observations of the resident revealed that s/he was on oxygen on the following dates and times: - 7/5/2022 at 10:39 AM - 7/6/2022 at 10:48 AM - 7/7/2022 at 9:40 AM - 7/8/2022 at 9:02 AM Further record review failed to reveal evidence of a care plan for oxygen. During a surveyor interview with the Director of Nursing Services (DNS) and the Assistant Director of Nursing Services (ADNS) on 7/8/2022 at approximately 12:59 PM, they revealed that they would have expected the resident to have a care plan in place for oxygen. 2. Record review revealed that Resident ID #329 was readmitted to the facility in June of 2022 and has diagnoses including, but not limited to, abnormalities of gait and mobility, altered mental status, and repeated falls. Review of the resident's progress notes revealed the following: - 6/28/2022 10:29 AM- .Resident was walking on the East hall, and fell . - 7/1/2022 6:43 PM- .staff informed writer that resident was on the floor . Further record review failed to reveal evidence of a care plan related to falls. During a surveyor interview on 7/8/2022 at 12:58 PM with the DNS and ADNS, they revealed that they would expect the resident to be care planned for falls. 3. Record review revealed that Resident ID #580 was admitted to the facility in November of 2021 with diagnoses including, but not limited to, schizoaffective disorder and vascular dementia. Review of a facility policy titled WANDERING MANAGEMENT SYSTEM, dated 4/2015 states in part, .A plan of care must be formulated with the Interdisciplinary Team .to determine the need for wander management system bracelet and documented in the Care Plan .Check every shift for placement and document .Check function of on a daily basis . Review of the resident's progress notes revealed the following: - 6/17/2022 7:39 PM- Resident had one episode of wandering unit exit seeking towards elevators .Wander guard placed on resident. Record review revealed the following physician's order: - Wander guard left ankle. Expiration date: September 2022. every shift -Start date- 06/14/2022 . Further record review failed to revealed evidence of a care plan for a wander guard. During a surveyor interview on 7/8/2022 at approximately 12:23 PM with the DNS and the ADNS, they revealed that they were unaware of the wander guard placement on the resident and would expect the wander guard to be addressed in the care plan.

CONCERN (E)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observations, record review, resident and staff interview, it has been determined that the facility failed to ensure that each resident receives adequate supervision to prevent accidents relative to smoking hazards for 6 of 6 residents reviewed, Resident ID #s 36, 53, 72, 78, 578, and 579 and failed to ensure a resident's environment remains as free of accident hazards as possible for 1 of 4 residents reviewed for elopement risk, who use a wander guard (a device used to alert staff if the resident is attempting to leave the building), Resident ID #117. Findings are as follows: 1. Review of a facility policy titled, RESIDENT SMOKING SCHEDULE, dated 3/15/2021, states in part, .All residents who want to smoke must be accompanied by a staff member or responsible party at all times .Staff smoking monitors are available for 15 minutes for each designated smoke time. Residents cannot give cigarettes to any other resident . A. Record review for Resident ID #36 revealed that s/he was admitted to the facility in July of 2021 with diagnoses including, but not limited to, dementia with behavioral disturbances, type 2 diabetes mellitus and hypertension. During surveyor observations of Resident ID #36, s/he was observed outside smoking unsupervised on the following dates and times: - 7/5/2022 at 1:25 PM - 7/6/2022 at 8:32 AM B. Record review for Resident ID #53 revealed that s/he was admitted to the facility in January of 2022 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (constriction of the airways), altered mental status, hypertension, and dysphagia (difficulty swallowing). Record review of an assessment titled SMOKING EVALUATION and SAFETY SCREEN, dated 5/31/2022, revealed s/he requires supervision during scheduled smoking activity. During a surveyor observation on 7/7/2022 at approximately 11:00 AM, s/he was observed outside smoking unsupervised. C. Record review for Resident ID #72 revealed that s/he was admitted to the facility in October of 2021 with diagnoses including, but not limited to, schizoaffective disorder, unspecified intellectual disabilities, and chronic obstructive pulmonary disease. Record review of an assessment titled SMOKING EVALUATION and SAFETY SCREEN, dated 5/31/2022, revealed s/he requires supervision during scheduled smoking activity. During a surveyor observation of the resident on 7/7/2022 at approximately 11:03 AM, s/he was observed outside smoking unsupervised. D. Record review for Resident ID #78 revealed that s/he was admitted to the facility in June of 2020 with diagnoses including, but not limited to, acute pulmonary edema and type 2 diabetes mellitus. Record review of an assessment titled SMOKING EVALUATION and SAFETY SCREEN, dated 5/31/2022, revealed s/he requires supervision during scheduled smoking activity. Surveyor observations of the resident revealed s/he was outside smoking unsupervised on the following dates and times: - 7/5/2022 at 1:25 PM and at 1:30 PM, observed dropping ashes into his/her lap - 7/6/2022 at 8:32 AM - 7/7/2022 at 10:55 AM E. Record review for Resident ID #578 revealed that s/he was admitted to the facility in June of 2022 with diagnoses including, but not limited to, chronic obstructive pulmonary disease and tobacco use. Record review of an assessment titled SMOKING EVALUATION and SAFETY SCREEN, dated 6/30/2022, revealed s/he requires supervision during scheduled smoking activity. Surveyor observations of the resident revealed s/he was outside smoking unsupervised on the following dates and times: - 7/5/2022 at 1:15 PM - 7/7/2022 at 8:49 AM - 7/7/2022 at 10:30 AM F. Record review for Resident ID #579 revealed that s/he was admitted to the facility in June of 2022 with a diagnosis including, but not limited to, chronic obstructive pulmonary disease. Record review of an assessment titled SMOKING EVALUATION and SAFETY SCREEN, dated 6/13/2022, revealed s/he requires supervision during scheduled smoking activity. During a surveyor observation of the resident on 7/7/2022 at approximately 10:55 AM, s/he was observed outside smoking unsupervised. During a surveyor interview on 7/7/2022 at approximately 11:05 AM with the Director of Nursing Services (DNS) and the Assistant Director of Nursing Service (ADNS), they revealed that they were unaware that residents were smoking unsupervised outside on the above dates and times. They further acknowledged that they would expect a staff member to be present in the smoking area while residents were outside smoking per the facility policy and the residents' smoking evaluations. 2. Review of a facility policy titled WANDERING MANAGEMENT SYSTEM, dated 4/2015 states in part, .A plan of care must be formulated with the Interdisciplinary Team .to determine the need for wander management system bracelet and documented in the Care Plan .Check every shift for placement and document .Check function of on a daily basis . Record review for Resident ID #117 revealed that s/he was admitted to the facility in July of 2019 with diagnoses including, but not limited to, alcoholic cirrhosis of the liver, traumatic subdural hemorrhage with loss of consciousness (brain bleed), and anxiety disorder. During surveyor observations, the resident was observed wearing a wander guard on his/her right ankle on the following dates and times: - 7/5/2022 at 10:58 AM - 7/6/2022 at 9:11 AM - 7/7/2022 at 9:13 AM - 7/8/2022 at 10:06 AM Record review revealed an elopement and wandering assessment dated [DATE], which states in part, .Resident IS at risk for elopement .Resident IS at risk for wandering . Record review failed to reveal a physician's order in place to check the function and placement of his/her wander guard each shift, per the facility policy. Further record review failed to reveal a care plan in place relative to elopement risk and wander guard use. During a surveyor interview with Nurse Staff B on 7/8/2022 at 10:18 AM, she revealed that residents with a wander guard should have a physician's order to check its placement and function every shift. During a surveyor interview with Nurse Staff C on 7/8/2022 at 10:26 AM, she revealed she was unaware that the resident had a wander guard in place. Additionally, she was unable to provide evidence that the wander guard was being checked for placement and function each shift. During a surveyor interview with the DNS and ADNS on 7/8/2022 at 10:56 AM, they acknowledged that the resident wears a wander guard, but were unable to provide evidence of a physician's order or care plan per the facility policy. Additionally, they were unable to provide evidence that the resident's wander guard was being checked for placement and function.

CONCERN (E)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that each resident's medication regimen is free of medication error rates of...

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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that each resident's medication regimen is free of medication error rates of 5% or greater. Based on 29 opportunities for error, there were 4 errors involving Resident ID #s 35, 49, and 113, resulting in an error rate of 13.79%. Findings are as follows: 1. Record review revealed Resident ID #35 had a physician's order for Metoprolol Succinate capsule extended-release 24-hour sprinkle 50 milligrams (mg), to give 50 mg by mouth one time a day. During a surveyor observation of the Medication Administration task on 7/7/2022 at approximately 8:20 AM with Certified Medication Technician (CMT), Staff E, he prepared to administer one Metoprolol 25 mg tablet crushed to the resident. During a subsequent surveyor interview with CMT Staff E on 7/7/2022 at approximately 8:35 AM, he acknowledged the physician's order was for Metoprolol 50mg. He also acknowledged that the physician's order indicated to administer a sprinkle capsule. 2. Record review revealed Resident ID #49 had a physician's order for Vitamin D tablet of 50 micrograms (2000 units), to give one tablet by mouth one time a day. During a surveyor observation of the Medication Administration task on 7/7/2022 at approximately 9:59 AM with CMT Staff F, the Vitamin D tablet was not administered per physician's order. 3. Record review revealed Resident ID #113 had a physician's order for Niferex tablet (iron combination), to give 150 mg by mouth in the morning. During a surveyor observation of the Medication Administration task on 7/7/2022 at approximately 8:36 AM with CMT Staff E, he administered the contents of a 150 mg Niferex capsule after opening it. The medication bottle had manufacturer's instructions indicating to not crush, chew, or open extended-release capsules or tablets, and not split extended-release tablets unless they have a score line. During a surveyor interview with the Director of Nursing Services on 7/7/2022 at approximately 2:41 PM, she revealed that she would expect staff to administer medications following the physician's order and she expects staff to follow the manufacturer's instructions on medication administration.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure all staff utilized Personal Protective Equipment (PPE) according to profess...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure all staff utilized Personal Protective Equipment (PPE) according to professional standards of practice to prevent the transmission of COVID-19 or other infectious diseases for 1 of 5 staff observed, Staff E and that all staff implemented infection control practices to help prevent and control infections related to following proper hand hygiene techniques during 2 of 3 resident dressing changes observed, Staff I, and Staff A. Findings are as follows: 1. Review of the facility's policy titled, Hand Hygiene, states in part, .The term hand hygiene includes both hand washing with soap and water and the use of alcohol based products that do not require use of water. Healthcare workers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to residents including: before resident contact; after contact with bloody body fluids, or contaminated surfaces; and after removing gloves . 1a. Review of Resident ID # 3's record revealed s/he was admitted to the facility in December of 2021, with diagnoses including, but not limited to, non-pressure chronic ulcer of other part of right foot with unspecified severity, peripheral vascular disease, and type 2 diabetes mellitus. Record review revealed the following physician's orders: - Left fifth toe: cleanse with WC [wound cleanser], skin prep area follow by ABD [abdominal pad] and kerlix [gauze cling] every day shift, dated 5/6/2022. - skin prep area to right lateral heel followed by ABD and kerlex one time a day, dated 5/12/2022. During a surveyor observation of Nurse Staff I, on 7/8/2022 at 10:17 AM she was observed applying gloves to provide a wound treatment to the resident's right lateral heel. After completing the wound treatment for the right heel, she then, with the same gloves, began removing the left foot dressing without performing hand hygiene. She stopped to remove her gloves and perform hand hygiene, then continued removing the resident's left foot dressing. Following the removal of the left foot dressing, she removed her gloves and left the resident's room to get more supplies. When she returned to the resident's room, she did not perform hand hygiene before applying new gloves to finish the dressing to the resident's left foot prior to completing the dressing change. During a surveyor interview immediately following the above observation with Staff I, she acknowledged she did not perform proper hand hygiene during the resident's dressing changes. During a surveyor interview on 7/8/2022 at 10:50 AM with the Assistant Director of Nursing Services (ADNS), she revealed she would expect the nurse to have performed hand hygiene appropriately. 1b. Review of Resident ID # 76's record revealed s/he was admitted to the facility in November of 2020, with diagnoses including, but not limited to, peripheral vascular disease, and type 2 diabetes mellitus with diabetic polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body). Record review revealed the following physician's order dated 7/6/2022, Clean open areas on the right buttocks with N/S [normal saline], Apply Silverdene cream, cover with DCD [dry clean dressing] until resolved B.I.D. [twice daily]. During a surveyor observation of Nurse Staff A, on 7/7/2022 at 10:52 AM she was observed providing wound treatment to the resident's buttocks with gloves on. Following the wound treatment, she took off the gloves, walked to the resident's bathroom, opened, and then closed the door as it was occupied. Staff Nurse A then obtained new gloves from her pocket and continued the resident's wound treatment and dressing change without performing hand hygiene in between. During a surveyor interview immediately following the above observation with Nurse Staff A, she acknowledged she did not perform proper hand hygiene between glove changes. During an interview on 7/8/2022 at approximately 11:00 AM with the DNS and the ADNS, they indicated that nurses are expected to follow the infection control policy regarding hand hygiene during dressing changes. 2. Review of the facility policy titled, Athena Healthcare Systems COVID-19 Facility Assessment, states in part, .Transmission Based Precautions: .For a resident with known or suspected COVID-19: staff wear .eye protection . During a surveyor observation on 7/5/2022 at approximately 12:00 PM, Certified Nursing Assistant, Staff H, was observed passing meal trays to residents in a COVID-19 quarantine area without wearing a face shield or goggles. During a surveyor interview on 7/5/2022 at 12:10 PM with Staff H, he acknowledged he was not wearing a face shield or goggles in the quarantine area. During a surveyor interview on 7/6/2022 at 12:10 PM with the Director of Nursing Services and ADNS, they revealed they would expect staff to wear full PPE including a face shield or goggles when in a COVID-19 quarantine area.

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on surveyor observation and staff interview, it has been determined that the facility failed to properly distribute and serve food under sanitary conditions relative to the serving of milk at an...

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Based on surveyor observation and staff interview, it has been determined that the facility failed to properly distribute and serve food under sanitary conditions relative to the serving of milk at an observed lunch meal. Findings are as follows: The State of Rhode Island Food Code 2018 Edition states in part, . Except during preparation, cooking or cooling .time/temperature control for safety food shall be maintained at 5 degrees C [celsius] 41 degrees F [fahrenheit] or less . During a surveyor observation of the lunch meal on 7/7/2022 at approximately 11:40 AM in the presence of the Food Service Director (FSD), the whole milk that was being served to the residents on the 3rd floor nursing unit was being served at 47 degrees Fahrenheit (F), temperature taken by the FSD. During a surveyor interview with the FSD immediately following the above observation, he acknowledged the temperature of the milk being served was not at 41 degrees F and a temperature recording had not been taken prior to meal service.

MINOR (B)

Minor Issue - procedural, no safety impact

Medical Records (Tag F0842)

Minor procedural issue · This affected multiple residents

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain accurately documented medical records on each resident relative to treatm...

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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain accurately documented medical records on each resident relative to treatment administration for 1 of 1 resident reviewed relative to TED stockings (compression stockings worn to help prevent the formation of blood clots in the lower legs), Resident ID #122 and relative to accurate documentation between the controlled substance record and the Medication Administration Record (MAR), for 2 of 2 residents reviewed, Resident ID #'s 64 and 581. Findings are as follows: 1. Record review for resident ID #122 revealed that s/he was admitted to the facility in June of 2022 with diagnoses including, but not limited to, history of falling and injury of the left ankle with subsequent surgical repair of the left ankle. Further record review revealed a physician's order dated 6/7/2022 for TEDs stocking to right leg only. On during the day and off at night. During surveyor observations on 7/6/2022 at approximately 9:00 AM and 2:30 PM, the resident was observed without a TED stocking on his/her right leg. Record review of the Treatment Administration Record (TAR) for July 2022 revealed the order was signed off as completed by the nurse for the 7 AM to 3 PM shift on 7/6/2022. During a surveyor interview with the resident on 7/6/2022 at approximately 2:30 PM, s/he revealed that s/he had not worn the TED stocking that day. During a surveyor interview with the Nurse, Staff D, she acknowledged that the resident was not wearing the stocking and stated she signed the TAR. During a surveyor interview with the Director of Nursing Services on 7/6/2022 at approximately 2:30 PM, she revealed that she would expect the nurse to document accurately. 2. Review of the facility policy titled, Narcotics, states in part, .Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling and record keeping in the facility, in accordance with Federal and State laws and regulations and require narcotic book documentation . Record review for Resident ID #64 revealed a physician order dated 6/25/2022 for Oxycodone (opioid medication used to relieve moderate to severe pain) 15 mg (milligram) tablet, give one tablet by mouth every 8 hours as needed for pain for 2 weeks for a pain scale of 5-10. Review of the controlled substance record and July 2022 MAR for this resident revealed the following: - On 7/6/2022, according to the controlled substance record, 3 tablets were removed, however, the MAR revealed that 2 tablets were administered to the resident. Further review of the controlled substance record and June 2022 MAR for this resident revealed the following: - On 6/28/2022, according to the controlled substance record, 3 tablets were removed, however, the MAR revealed that 2 tablets were administered to the resident. - On 6/27/2022, according to the controlled substance record, 3 tablets were removed, however, the MAR revealed that 2 tablets were administered to the resident. During a surveyor interview on 7/8/2022 at 10:00 AM with Nurse Staff G, she acknowledged that she failed to accurately document in the MAR when administering the oxycodone medication to the resident on 6/28/2022. 3. Review of the record for Resident ID #581 revealed a physician order dated 6/22/2022 for Lorazepam (medication used to treat serious seizures and anxiety) 0.5 mg tab, give 1 tablet by mouth every 8 hours. Review of the controlled substance record and July 2022 MAR for this resident revealed the following: - On 7/8/2022, according to the controlled substance record, 1 tablet was removed, however, the MAR failed to reveal evidence that the medication was administered to the resident. Additional review of the July 2022 MAR revealed this medication was discontinued on 7/7/2022. 3a. Further review of the record for Resident ID #581 revealed a physician order dated 6/16/2022 for Methadone (a synthetic analgesic medication used to treat an addiction to opioids and/or pain) 10 mg tab, give 4 tablets by mouth every 8 hours. Review of the controlled substance record and July 2022 MAR for this resident revealed the following: - On 7/2/2022, according to the controlled substance record, 2 tablets were removed, however, the MAR revealed that 3 tablets were administered to the resident. During a surveyor interview with the Director of Nursing Services and the Assistant Director of Nursing Services on 7/8/2022 at approximately 12:30 PM, they revealed that they would expect that the nurse would document in both the MAR and the controlled substance record when administering controlled medications. Additionally, they indicated that they would expect the nurse to verify that an order is active prior to administering the medication.

Oakland Grove Health Care Center

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