Every finding on record at Adviniacare Providence Dodge Rehab Center, LLC

Based on record review and staff interview, the facility failed to ensure that the resident environment remains as free of accident hazards as possible, as staff failed to follow established safety protocols to prevent and extinguish a kitchen grease fire. Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health by the State Fire Marshal on 8/24/2026 revealed that the facility had a small stove fire over the weekend.Review of a facility provided undated procedure titled GREASE FIRE SAFETY & PREVENTION EDUCATION states in part, .Cooking grease and oil can become extremely hot and may ignite. A grease fire can spread rapidly, especially when oil is overheated or when water is introduced.Do not allow oil to smoke or overheat.NEVER USE WATER ON A GREASE FIRE.Water can instantly turn to steam and violently propel burning grease, causing the fire to spread and potentially causing severe burns. Never carry or move a burning pan or fryer .IF A SMALL GREASE FIRE STARTS.carefully slide a metal lid or sheet pan over the pan to smother the flames. Keep it covered.Review of the United States Fire Administration/National Fire Data Center article dated August 2005 titled Structure Cooking Fires states in part, .care should be taken when cooking with.butter, or other greasy foods that are highly flammable and can easily splatter or spill from pots and pans. Cooking aids are available to limit grease splattering. Do not attempt to extinguish grease-based fires with water as it reacts violently when poured on hot grease or oil.Record review on 8/25/2026 of a written statement dated 8/24/2026 written by the Food Service Director (FSD) revealed that he received a text message from the Cook, Staff A, informing him that a pan of butter on the stove began to smoke. The statement indicated that Staff A moved the pan to the 3-compartment sink, and introduced water, which caused steam and activated the fire suppression system directly above the sink.During an interview on 8/25/2026 at 12:03 PM, Staff A stated that she had a pan of butter melting on the stove and turned around to complete other kitchen duties. Staff A stated that when she turned back to the stove, a flame had ignited, causing her to panic and forget the facility's protocol. Staff A stated that she turned off the stove burner, moved the burning pan to the 3-compartment sink, and filled it with water. Staff A acknowledged this action caused a steam that triggered the kitchen's automated fire suppression system. Staff A further acknowledged that she should not have heated the butter at a high temperature and knew that water should never be applied to a grease fire.During a surveyor interview on 8/25/2026 at 9:35 AM, the FSD acknowledged that Staff A failed to follow the facility's protocol regarding grease fires.

Based on clinical record review and staff interview, the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic for 1 of 2 residents reviewed for antibiotic use, Resident ID #12.Findings are as follows:Review of a facility reported incident submitted to the Rhode Island Department of Health on 12/26/2025 revealed that on 12/24/2025, Resident ID #12 had fallen transferring him/herself from the bathroom, was noted to have a change in condition following the fall and was transferred to an acute care hospital where s/he was admitted for sepsis. Additionally, s/he had recently completed a course of intravenous (IV) antibiotics at the facility secondary to a urinary tract infection (UTI).Review of a facility policy titled, ANTIBIOTIC STEWARDSHIP last revised 9/10/2025, states in part, .Antibiotic will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. Antibiotic Stewardship refers to a set of commitments and activities designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.If an antibiotic is indicated, prescribers will provide complete antibiotic orders including.duration of treatment start and stop date number of days of therapy.Record review revealed Resident ID #12 was readmitted to the facility in January of 2026 with diagnoses including, but not limited to, sepsis and bacteremia (the presence of bacteria in your blood which can be serious and require antibiotics).Record review revealed that the resident tested positive for a UTI and the provider ordered vancomycin (an antibiotic) 1 gram every 12 hours for 12 days beginning on 12/2/2025, indicating the resident was to receive a total of 24 doses.Review of an Antibiotic Time Out assessment dated [DATE], completed by the Infection Preventionist (IP), revealed that the vancomycin ordered for the resident was reviewed with the resident's Nurse Practitioner, Staff C. Review of the December 2025 Medication Administration Record revealed the resident received 25 doses of the vancomycin instead of the 24 doses that were prescribed.During a surveyor interview on 1/23/2026 at approximately 11:20 AM with Staff C, she revealed that she was unaware that the resident received an extra dose of his/her vancomycin. During a surveyor interview on 1/23/2026 at approximately 1:10 PM with the IP, in the presence of the Director of Nursing Services, she acknowledged completing the antibiotic time out for the vancomycin and failed to identify that the resident was scheduled to receive an additional dose of vancomycin.

Based on clinical record review and staff interview, the facility failed to provide appropriate treatment and services for a resident who sustained a fall in the facility, was treated with antibiotics for a urinary tract infection (UTI), and subsequently fell again and later was admitted to the hospital with sepsis (a life threatening, emergency response to infection where the immune system triggers widespread inflammation, leading to potential organ failure, shock, and death) for 1 of 2 residents reviewed for falls, Resident ID #12.Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 12/26/2025 revealed that on 12/24/2025, Resident ID #12 had fallen transferring him/herself from the bathroom, was noted to have a change in condition following the fall and was transferred to an acute care hospital where s/he was admitted for sepsis. Additionally, s/he had recently completed a course of intravenous (IV) antibiotics at the facility secondary to a UTI.1a. Record review revealed Resident ID #12 was readmitted to the facility in January of 2026 with diagnoses including, but not limited to, sepsis and bacteremia (the presence of bacteria in your blood which can be serious and requires antibiotics).Record review revealed the resident had an unwitnessed fall on 11/20/2025.Review of a progress note dated 11/20/2025 at 8:30 AM authored by the Nurse Practitioner (NP), Staff C, revealed that the resident was seen for an unwitnessed fall and increased confusion. Additionally, Staff C ordered blood work and a urine sample to be obtained to evaluate for any underlying causes.Record review revealed a urine sample was obtained on 11/21/2025, however the lab determined the urine specimen was suggestive of contamination and to repeat testing if it was clinically indicated. Additionally, it indicated the method of specimen collection was a clean catch (the least invasive way to collect a urine sample).Review of a progress note dated 11/24/2025 revealed Staff C had reviewed the bloodwork and urine specimen and ordered another urine specimen to be collected.Record review revealed a second urine sample was obtained on 11/25/2025, however the lab determined the urine specimen was suggestive of contamination and to repeat testing if it was clinically indicated. Additionally, it indicated the method of specimen collection was a clean catch.Review of a provider order dated 11/26/2025 with a start time of 11:00 PM revealed to obtain a urine specimen via straight catheterization (a method to collect urine that involves inserting a thin, flexible tube called a catheter through the urinary tract opening and into the bladder) to rule out a UTI every shift. Additional instructions indicated to discontinue the order once the specimen is obtained.Further review revealed a progress note dated 11/28/2025 at 12:59 PM indicated that the urine specimen was collected, the resident tolerated the procedure well, and the lab was contacted to pick up the urine specimen.Review of a progress note dated 12/1/2025 revealed the result of the urine specimen collected on 11/28/2025 was positive for a UTI with two organisms growing a colony count of greater than 100,000 (indicative of a significant bacterial load). Additionally, the resident was to begin antibiotic therapy that included two antibiotics and a probiotic.Further review of the progress notes revealed a note dated 12/2/2025 at 11:15 AM authored by Staff C that revealed the resident is to receive vancomycin (an antibiotic) 1 gram (g) intravenously twice daily at 9:00 AM and 9:00 PM for 12 days. Additionally, staff were to monitor the vancomycin trough levels (Refers to the lowest concentration of the antibiotic in the bloodstream before the next dose is administered. Vancomycin trough levels are crucial for ensuring effective treatment with target levels typically ranging from 10 to 20 mg/L [milligrams per liter] depending on the severity of the infection) before the fourth dose with an ideal trough level of 15-20 mg/L.1b. According to an article in the National Library of Medicine titled, Therapeutic Monitoring of Vancomycin in Adult Patients: A Consensus Review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists states in part, Optimal Trough Concentration for Complicated Infections.Vancomycin serum trough concentrations of 15-20 mg/L are recommended to improve penetration, increase the probability of obtaining optimal target serum concentrations and improve clinical outcomes.Review of the December 2025 Medication Administration Record revealed the resident received vancomycin from 12/2 through 12/14 with varying dosages based on the vancomycin trough level as follows:-12/2 9:00 PM through 12/10 9:00 AM: Vancomycin 1 gram-12/10 9:00 PM through 12/12 9:00 AM: Vancomycin 1,250 mg-12/12 9:00 PM through 12/14 9:00 PM: Vancomycin 1 gramRecord review failed to reveal evidence that a vancomycin trough level was obtained prior to each fourth dose on the following dates and times:-12/4/2025 before 9:00 AM-12/6/2025 before 9:00 AM-12/8/2025 before 9:00 AMRecord review revealed the first vancomycin trough level was initially obtained on 12/10/2025, indicating 3 opportunities to obtain a vancomycin trough level as indicated by the NP were missed.Review of the vancomycin trough level lab document dated 12/10/2025 revealed that the trough level was 12.1 mg/L and was not within the 15-20 mg/L therapeutic range as desired.Review of a progress note dated 12/10/2025 at 2:39 PM authored Staff C revealed the trough level was 12.1 mg/L, and the vancomycin dose was increased from 1 g to 1,250 mg.Record review revealed the resident completed his/her course of antibiotic therapy for his/her UTI on 12/14/2025.Review of progress notes dated 12/24/2025, 10 days following the completion of his/her antibiotic therapy for a UTI, revealed that the resident experienced a fall, was bleeding from his/her genital area, presented not at baseline and was shaky, unable to stand.pale, and s/he was subsequently transferred to an acute care hospital and was admitted with sepsis.Review of the hospital documentation dated 1/2/2026 revealed that the resident presented with a concern for sepsis with the focus of infection deemed to be urinary. Additionally, the resident received broad spectrum antibiotics, including vancomycin, as well as 2 L of fluids and 1 unit of blood.During a surveyor interview on 1/23/2026 at approximately 11:20 AM with Staff C, she revealed that she would expect the staff to have obtained the vancomycin trough levels after the 3rd dose and before the 4th dose to ensure that the vancomycin trough levels remain within the therapeutic target range of 15-20 mg/L. Additionally, she acknowledged that the vancomycin trough levels were not completed on 12/4, 12/6, and 12/8 before 9:00 AM and should have been, and that the vancomycin trough level on 12/10/2025 was subtherapeutic.During a surveyor interview on 1/23/2026 at approximately 1:10 PM with the Director of Nursing Services, she was unable to provide evidence that facility provided appropriate treatment and services for a resident diagnosed with a UTI who subsequently fell and was admitted to an acute care hospital for sepsis.During a surveyor interview on 1/23/2026 at approximately 4:00 PM with a facility pharmacy representative, he revealed that there is probably a higher likelihood of failing to destroy an infectious organism if the vancomycin trough levels are sub-therapeutic.Cross reference F 881

Based on clinical record review, and resident and staff interviews, the facility failed to keep a resident free from physical abuse for 1 of 2 residents that was involved in a physical altercation that resulted in the victim sustaining injuries to his/her face, Resident ID #6. Findings are as follows:Review of a facility reported incident submitted to the Rhode Island Department of Health on 1/7/2026 revealed that on 1/6/2026 at 9:00 AM two residents, Resident ID #s 6 and 7, were heard screaming in their room; staff immediately rushed to the room to separate them. Additionally, one of the residents, Resident ID # 6, was noted to have blood on his/her lower and upper lips.Review of a facility policy, untitled and last revised on 10/23/2022 states in part, .the facility prohibits the mistreatment.and abuse of residents.the facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident.abuse. According to the document, abuse is defined as the willful infliction of injury.with resulting physical harm, pain, or mental anguish.Record review revealed Resident ID #6, the victim, was admitted in December of 2023 and readmitted to the facility in January of 2026 with diagnoses including, but not limited to, end stage renal disease, anemia and dependence on renal dialysis.Record review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident is cognitively intact. Further review revealed the resident is dependent on staff for all activities of daily living.Record review of the care plan revised on 7/29/2024 revealed that Resident ID #6 exhibits behaviors related to verbal aggression with an intervention to monitor episodes of such behaviors. Additional review of the care plan dated 11/5/2025 revealed that Resident ID #6 requires assistance from staff with activities of daily living and mobility, related to a decrease in activity tolerance.Record review of the nursing progress notes for Resident ID #6 revealed the following:-1/6/2026 at 3:57 PM, authored by the resident's provider revealed in part, she noted that the resident sustained a lump to his/her left cheek, bruising to the right side of his/her face, and his/her upper and lower lips related to an alleged altercation with his/her roommate this morning.-1/6/2026 at 10:10 PM, authored by Licensed Practical Nurse (LPN), Staff A, revealed in part, that at approximately 9:00 AM staff heard screaming from the residents' room and rushed there to find Resident ID #7 (the perpetrator) standing in front of Resident ID #6 (the victim) holding his/her meal tray. Additionally, Resident ID #6 stated that Resident ID #7 hit his/her in the face and Resident ID #6 was noted to have a cut to both his/her upper and lower lips.Review of the skin evaluation dated 1/6/2026 for Resident ID #6, after the incident revealed the following:-Swelling to his/her eye-A laceration to the upper and lower lips, mild facial swelling, and blood noted.Record review revealed that Resident ID #7, the perpetrator, was admitted to the facility in January of 2018 and readmitted in March of 2025 with diagnoses including, but not limited to, anxiety disorder and delusional disorder.Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 11 out of 15, indicating the resident has moderate impaired cognition.Review of the care plan revised on 8/1/2024 indicated that Resident ID #7 exhibits behaviors including verbal aggression and increased agitation. Interventions include, but are not limited to, staff to intervene when the resident becomes agitated, document all behaviors and attempt to identify a pattern to target interventions, and encourage the resident to take medications as ordered.Review of the nursing progress notes for Resident ID #7 revealed the following:-12/18/2025, the resident has had an increase in agitation and aggressive behaviors toward staff and a new recommendation for Trazodone (a medication prescribed to treat anxiety and depression) 50 milligrams (mg) twice daily has been initiated.-12/29/2025, the resident has been throwing his/her meal tray on the hallway floor despite having been re-directed several times to leave the tray in his/her room-12/30/2025, the resident continues to throw his/her meal tray in the hallway causing all the plates to shatter. The resident is not able to be redirected, and s/he is non-compliant with re-education regarding safety-1/1/2026, the resident was observed throwing his/her meal tray on the hallway floor despite being asked to leave it on the table for staff-1/6/2026, the resident had violent behavior when s/he had an alleged altercation with his/her roommate, and s/he was relocated to a different room1/6/2026, the resident reported that s/he asked his/her roommate to close the door to their room, but his/her roommate refused, and s/he struck his/her roommateRecord review of the Psychiatric team evaluations for Resident ID #7 revealed the following:-12/30/2025, the resident continues to exhibit restlessness and agitation with care. Plan, continue to monitor and document changes in mood, behavior disturbance and anxiety-1/6/2026, the resident assaulted his/her roommate. The resident has been non complaint with his/her medications.Review of a physician's order dated 12/16/2025 indicates to monitor Resident ID #7's behaviors and document the number of episodes every shift.Review of January 2026 Treatment Administration Record failed to reveal evidence that Resident ID #7 had behaviors on 1/6/2026 when s/he was involved in a physical altercation with his/her roommate. During a surveyor interview on 1/21/2026 at 10:55 AM with Resident ID #7, s/he revealed that s/he punched his/her roommate in the face.During a surveyor interview on 1/21/2026 at 11:01 AM with Resident ID #6, s/he revealed that Resident ID #7 hit him/her multiple times on the head and his/her face while s/he sat in his/her wheelchair after Resident ID #7 asked him/her to close their bedroom door and s/he refused. Further, Resident ID #6 revealed that his/her roommate had been physically aggressive towards him/her in the past and the facility was aware of this.During a surveyor interview on 1/21/2026 at 11:15 AM with Staff A, she revealed that on 1/6/2026 at approximately 9:00 AM, staff heard Resident ID #6 scream, and they rushed to his/her room to find Resident ID #6 sitting in his/her wheelchair with bloody lips and a puffy right sided face. Additionally, Resident ID #6 indicated that s/he was hit by Resident ID #7, who was observed standing in front of him/her. Staff A also revealed that Resident ID #7 has a history of aggressive behaviors.During a surveyor interview on 1/21/2026 at approximately 3:00 PM and 1/22/2026 at approximately 12:00 PM with the Administrator and the Director of Nursing Services (DNS), they acknowledged that Resident ID #7 has a history of aggressive behaviors. The Administrator and the DNS indicated that they were made aware of the altercation between both resident's, which resulted in Resident ID #6 sustaining bloody lips and a swollen face and Resident ID #7 was moved to a private room immediately following the incident. Additionally, they were unable to provide evidence that Resident ID #6 was kept free from abuse.

Based on clinical record review and staff interview, it has been determined that the facility failed to ensure that a resident who requires dialysis (a medical treatment that filters waste products, toxins, and excess fluid from the blood when kidneys have failed) receive such services consistent with professional standards of practice, for 1 of 1 resident reviewed who was prescribed the medication Sevelamer (a medication prescribed primarily to treat elevated phosphorus levels in the blood for individuals with chronic kidney disease and are on dialysis) to treat his/her elevated blood phosphorus levels. This failure resulted in Resident ID #6's blood phosphorus level to further rise. Findings are as follows:Record review revealed the resident was readmitted to the facility in January of 2026 with diagnoses including, but not limited to, end stage renal disease (the final stage of chronic kidney disease when the kidneys can no longer function on their own) and dependence on renal dialysis.Record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident is cognitively intact. Further review of the MDS indicated that the resident is dependent on staff for all activities of daily living.Review of the resident's care plan revised on 3/14/2024 indicated that the resident requires hemodialysis three times a week related to end stage renal disease, with an intervention including, but not limited to, coordinate medications with dialysis days.Record review revealed a physician's order dated 10/1/2025 for Sevelamer 3200 milligrams (mg) three times a day for hyperphosphatemia (an elevated blood phosphorus level). Record review of the November and December 2025 and the January 2026 Medication Administration Records failed to reveal evidence that the resident received the medication Sevelamer as ordered on the following dates and times:11/3/2025 - 12 PM11/4/2025- 8 AM11/5/2025 -12 PM11/10/2025- 12 PM11/12/2025- 12 PM11/14/2025- 12 PM11/28/2025- 12 PM12/3/2025 - 5 PM12/4/2025- 8:00 AM, 12:00 PM and 5:00 pm12/5/2025- 8:00 AM and 12:00 PM12/7/2025- 5:00 PM12/8/2025- 8:00 AM, 12:00 PM and 5:00 PM121/10/2025- 12:00 PM12/12/2025- 12:00 PM12/17/2025- 12:00 PM12/21/2025- 12:00 PM12/23/2025- 12:00 PM12/28/2025- 12:00 PM12/30/2025- 12:00 PM1/14/2026- 4:30 PM1/15/2026- 7:30:00 AM, 11:30 AM and 4:30 PM1/16/2026- 4:30 PM1/17/2026- 11:30 AM and 4:30 PM1/18/2026- 7:30 AM, 11:30 AM and 4:30 PM1/19/2026- 7:30 and 11:30 AM1/20/2026- 11:30 AM1/21/2026- 11:30 AMThe MARs indicate that the resident failed to receive the medication Sevelamer for a total of 27 doses, over the course of 3 months.Record review of the phosphorus levels from the hemodialysis center indicated on 12/19/2025 the resident had an elevated phosphorus serum level of 5.5 (the normal range for phosphorus levels are 2.5-4.5). Additional review of the document revealed that the resident's phosphorus level on 1/12/2026 was now 7.5, indicating his/her phosphorus level had increased 2 mg/deciliter (dl) and was now 3 mg/dl higher than the normal level.During a surveyor interview on 1/23/2026 at approximately 2:00 PM with Registered Nurse (RN), Staff B, she revealed that the resident's Sevelamer has not been available for a while to administer to him/her. Additionally, Staff B revealed that the medication Sevelamer was also put on hold because it was not available however, they recently received the medication last week from the hemodialysis center.During a surveyor interview on 1/23/2026 at 2:22 PM with the hemodialysis center staff RN, she revealed that the Sevelamer is ordered to be administered to the resident three times a day with meals. Additionally, she indicated that the hemodialysis center was unaware that the resident had ran out of Sevelamer, and that the facility had not communicated this to the hemodialysis center as they provide this medication to the facility. During a surveyor interview on 1/23/2026 at 2:34 PM with the Nurse Practitioner (NP), she indicated that she was made aware that the resident had missed doses of the Sevelamer. Additionally, the NP stated, the increased phosphorus levels are due to [him/her] not receiving the medication.During a surveyor interview on 1/23/2026 at 3:10 PM with the Director of Nursing Services (DNS), she revealed that she was initially unaware that the resident was receiving his/her medication supply of Sevelamer from the hemodialysis center and she was recently made aware that the resident could obtain the medication from the dialysis center. Additionally, the DNS was unable to provide evidence that the resident was administered the Sevelamer, as ordered.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 4 residents reviewed for oxygen therapy, Resident ID #105.Findings are as follows:Review of the policy titled, OXYGEN - CYLINDERS dated 1/2023, states in part, .Oxygen is administered by Licensed Nurses with a Physician's Order in order to provide a resident with sufficient oxygen to their blood and tissues.PROCEDURE: .Look at the pressure gauge to determine how much oxygen is in the cylinder. A full cylinder will register around 2200 PSI [Pounds per Square Inch].Record review revealed Resident ID #105 was readmitted to the facility in March 2025 with diagnoses including, but not limited to, non-ST elevation myocardial infarction (a type of heart attack) and chronic obstructive pulmonary disease (a progressive lung disease that causes airway inflammation and damage, making breathing difficult and reducing oxygen intake. As COPD advances, many patients experience hypoxia, low oxygen levels in body tissues, often requiring supplemental oxygen).Record review revealed a physician order dated 7/7/2025 for oxygen at 2 liters/minute (LPM) via nasal cannula as needed.During a surveyor observation on 8/5/2025 at 1:57 PM, the resident did not appear to be in distress, but his/her portable oxygen cylinder was observed to be empty.Record review of the medication and treatment administration records for August of 2025 failed to reveal evidence that the resident's portable oxygen was being monitored to ensure that s/he receives the oxygen that s/he needs.During a surveyor observation of the resident, accompanied by a simultaneous interview on 8/5/2025 at 3:07 PM in the presence of the Nursing Unit Manager, Staff G, she acknowledged that the resident's oxygen cylinder was empty. Staff G then assessed the resident's oxygen saturation level using a pulse oximeter, which registered 78% (normal range: 95-100%; levels below 95% increase the risk of tissue and organ damage, and levels below 88% constitute a medical emergency requiring immediate intervention). Staff G subsequently replaced the resident's oxygen cylinder.During a follow up observation of the resident on 8/5/2025 at 3:27 PM, in the presence of Staff G, his/her oxygen saturation level was between 96% to 97% on 2 LPM.During a surveyor observation of the resident on 8/6/2025 at 9:03 AM, his/her oxygen cylinder was observed to be empty. Staff G was notified and obtained the resident's oxygen saturation level, which was noted to fluctuate between 85% to 86%.During a surveyor interview with Staff G immediately following the above observation, she indicated that there were no functional oxygen concentrators (a medical device that provides a continuous flow of oxygen to individuals who require supplemental oxygen) available on the unit, so the resident has been utilizing the oxygen cylinders since 8/4/2025. Additionally, she indicated that she was unsure how long an oxygen cylinder lasts.Record review of the facility document titled E CYLINDER TIME CHART, revealed that the facility's oxygen cylinder is a 2000 PSIG lasts for approximately 4.5 hours if utilized for a resident with a physician's order of oxygen at 2 LPM.Surveyor observation revealed that functional oxygen concentrators were available in the facility, and the resident was provided with one on 8/6/2025.During a surveyor interview on 8/6/2025 at 9:34 AM with the Director of Nursing Services (DNS), she indicated that Resident ID #105 should have been utilizing an oxygen concentrator when s/he is in his/her room and a portable oxygen cylinder when s/he is out of his/her room. Additionally, she revealed that she would expect the staff to monitor the resident frequently if s/he has been placed on a portable oxygen cylinder.

Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed in accordance with professional standards for food service safety, relative to the main kitchen and two of three kitchenettes.Findings are as follows:1. Record review of Rhode Island Food Code, 2022 Edition, Section 3-501.17 states in part, .READY -TO-EAT-TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees Celsius or 41 degrees Fahrenheit or below for a maximum of 7 days. The day of preparation shall be counted as Day 1 .a. During the initial tour of the kitchen on 8/4/2025 at 8:20 AM in the presence of the Food Service Director (FSD), the following was observed without a label or a date:In the walk-in refrigerator:- opened butter with visible food matter on it- 9 bowls of pudding- 6 plates and 8 bowls of lemon merengue pie- an opened block of cheese- a hotel pan of sliced tomatoes- a hotel pan of cut up lettuce- an opened 15-ounce container of ricotta cheeseDuring a surveyor interview with the FSD following the above observation, she acknowledged that the above-mentioned items failed to be labeled and dated appropriately, per the food code.b. Record review of the policy titled FOOD FROM OUTSIDE dated 1/2023 states in part: .Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that it is clearly distinguishable from facility-prepared food.All refrigerated foods should be discarded within 48 [hours].During a surveyor observation of the second-floor kitchenette's refrigerator on 8/5/2025 at 7:44 AM, the following items failed to be dated:- two food containers labeled for two different residents- an opened and uncovered Styrofoam cup with red liquid insideAdditionally, an opened butter was noted to be placed inside a biohazard bag.During a surveyor interview with the FSD following the above observation, she acknowledged that the items in the kitchenette's refrigerator failed to be labeled and dated appropriately, per the facility policy.c. During a surveyor observation of the third-floor kitchenette's refrigerator on 8/5/2025 at 8:06 AM, the following items failed to be dated:- a resident's food with a room number- a resident's food inside a black bag- a resident's food in a bagDuring a surveyor interview with the FSD following the above observation, she acknowledged that the items failed to be labeled and dated appropriately, per the facility policy.2. Record review of The Rhode Island Food Code 2022 Edition 4.601.11 reads in part, .(A) equipment food contact surfaces .shall be clean to sight .During a surveyor observation of the main kitchen on 8/4/2025 at 11:44 AM, a kitchen fan with an accumulation of dust was noted to be blowing towards food that was being prepared.During a surveyor interview with the FSD immediately following the above observation, she acknowledged the presence of dust accumulation on the fan.3. Record review of the Rhode Island Food Code 2022 Edition 2-402.11 reads in part, .FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair .to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS .During a surveyor observation on 8/4/2025 at 12:12 PM Dietary Aide, Staff J, failed to have his hair fully covered by a hair net.During a surveyor interview on 8/5/2025 at 8:11 AM with the Dietitian, she acknowledged that Staff J should've been wearing a hair net that covers all of his hair.

Based on record review and staff interview, it has been determined that the facility failed to implement and revise the comprehensive care plan for 1 of 3 residents reviewed for weight loss, Resident ID #119 and 1 of 1 resident reviewed for fluid restriction, Resident ID #7.Findings are as follows: Record review of a facility policy titled Care Plan - Comprehensive last revised 10/22/2025, states in part .The comprehensive, person centered care plan will.describe that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.should be developed within seven (7) days of the completion of the required comprehensive assessment.when there has been a significant change in the resident's condition.1. Record review revealed Resident #119 was admitted to the facility in August of 2021, with diagnoses including, but not limited to, dementia without behavioral disturbance and adult failure to thrive.During a surveyor interview on 8/4/2025 at 1:21 PM with a member of the resident's family, s/he revealed that the family will come to feed the resident often. S/he further revealed that the resident will not eat if not fed.Record review of the residents Significant Change MDS dated [DATE], indicated that indicated the resident requires substantial/maximum assistance with eating. Substantial/maximum assistance is defined as the helper providing more than half the effort to complete the task.Review of a care plan revised on 7/28/2025 revealed, that the resident has a self-care performance deficit related to activity intolerance and confusion. The care plan contained a staff intervention dated 7/17/2025 that the resident required partial assistance of one staff member with eating. This care plan failed to be updated to reflect the resident's current needs for substantial/maximal assistance with eating.Record review of a Task titled Eating where staff document the level of assistance the resident was provided with meals for the period of 7/25/2025 through 8/5/2025 revealed that for 29 of 36 entries were documented as the resident eating independently.Surveyor observations during the breakfast meal on 8/7/2025 revealed the following:-8:42 AM the resident's breakfast tray was dropped off. The resident was in bed still sleeping.-8:48 AM a staff member entered the room helped the resident to sit in the bedside chair and told the resident that it was time to eat. Then the staff member left the room.-8:50 AM another staff member entered the resident's room and set up his/her tray, opening items on the tray for the resident, but did not assist the resident with eating. Then the staff member left the room.-8:53 AM a staff member went into the room to turn on the resident's light. This staff member then left the room without assisting the resident to eat.-8:55 AM- a staff member entered the room to speak with the resident's roommate, but did not interact with Resident ID #119.-9:03 AM- a staff member entered the room to administer the resident's medication, but did not assist the resident to eat.-9:07 AM- the resident stood up and turned off the light, then s/he laid down in his/her bed.During a surveyor observation and interview on 8/7/2025 at 9:09 AM, Registered Nurse (RN), Staff D, removed the resident's breakfast tray from the room. Staff D revealed that the resident is not a big eater, but s/he can eat independently. Staff D further acknowledged that the resident only drank the milk carton that was supplied on the tray.During a surveyor interview on 8/7/2025 at 10:31 AM with Licensed Practical Nurse (LPN) Staff F, she revealed that someone should sit with the resident to encourage and assist with eating. She further revealed that the resident eats better that way.During a surveyor interview on 8/7/2025 at 11:38 AM with the MDS Coordinator, she revealed that it was decided that the resident needed substantial/maximal assistance with meals when they met to discuss the resident's care needs. She further stated she would expect that a staff member would sit with the resident for meals and provide assistance with eating.During a surveyor interview on 8/7/2025 at 11:44 AM with the MDS Coordinator, she acknowledged that the residents comprehensive care plan failed to be revised to include his/her change in functional status related to his/her assistance needs with meals.2. Record review revealed Resident ID #7 was admitted to the facility in April of 2025 with diagnoses including, but not limited to, chronic kidney disease and dependence on renal dialysis (a treatment that filters waste and excess fluid from the blood when the kidneys are unable to do so).Record review revealed a physician's order dated 5/13/2025 for a fluid restriction of 1000 milliliters (ml) per day. Further review revealed that the order had been discontinued on 7/14/2025.Record review of a care plan last revised on 7/16/2025 indicated that the fluid restriction was still in place.During a surveyor interview on 8/7/2025 at 11:49 AM with the MDS Coordinator, she acknowledged that the fluid restriction was not removed from the care plan when the physician's order was discontinued and should have been.

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 relative to the facility's failure to schedule appointments for physician specialists, for 1 of 6 residents reviewed, Resident ID #1, and for wound care for 1 of 3 residents reviewed, Resident ID #57.Findings are as follows:A. Record review revealed Resident ID #1 was admitted to the facility in May of 2023 and readmitted in July of 2025, with diagnoses including, but not limited to, benign prostatic hyperplasia (BPH - an enlarged prostate), urinary retention, malignant pleural effusion (occurs when cancer cells spread to the lining of the lungs), and multiple myeloma not having achieved remission (a cancer that does not respond to treatment).Record review of a Significant Change Minimum Data Set Assessment (MDS) dated [DATE], revealed an active diagnosis of cancer, and that the resident is frequently incontinent of urine.Record review revealed the following:- 10/24/2024 - a nursing progress note indicating that a request for a neurological assessment was made.- 10/24/2024 - a physician's order was entered for a neurology consult to be made to rule out dementia.- 11/6/2024 - a nursing progress note revealed that a request from the resident's oncologist (a physician who specialized in treating patients diagnosed with cancer) was made for the resident to see a urologist.- 11/7/2024 - a nursing progress note revealed that the resident requested to see a urologist due to urinary frequency.- 3/26/2025 - a nursing progress note revealed that the resident returned from an oncology appointment and a new order for a urology consult was provided related to his/her BPH.- 5/17/2025- a physician's order was provided for the resident to have a neurology consult to rule out a diagnosis of dementia.- 5/21/2025- a nursing progress note indicated the neurology appointment request was submitted to the scheduler.- 6/18/2025 - a urology appointment was requested due to the resident complaining of severe frequent urination during the night.Record review failed to reveal evidence that a neurology appointment was scheduled for the resident after it was requested by a provider on two occasions, 10/24/2024 and 5/17/2025.Record review failed to reveal evidence that a urology appointment was scheduled for the resident after it was requested by a provider on three occasions, on 11/6/2024, 3/26/2025 and 6/18/2025.During a surveyor interview on 8/6/2025 at 8:33 AM with Nurse Practitioner (NP), Staff A, she indicated that she would have expected the resident to have had the consults with neurology and urology scheduled when as they were requested.During a surveyor interview on 8/6/2025 at 12:52 PM with the Assistant Director of Nursing Services, in the presence of the Director of Nursing Services, she acknowledged that there were multiple requests for both neurology and urology appointments since October of 2024. Additionally, she revealed that she would have expected these appointments to have been scheduled when the requests were submitted. Furthermore, she acknowledged that none of these appointments were scheduled prior to this concern being brought to the facility's attention by the surveyor.B. Record review revealed Resident ID #57 was readmitted to the facility in April of 2024 with diagnoses including, but not limited to, malignant neoplasm (cancer) of the brain and colon (a part of the large intestine). Additionally, it revealed that s/he receives chemotherapy every three weeks.Review of a psychosocial evaluation dated 7/17/2025, revealed a Brief Interview for Mental Status score of 15 out of 15, indicating the resident is cognitively intact.Record review revealed a physician note dated 8/1/2025 that indicates the resident was assessed due to a complaint of extremity pain and presented with a toenail that was lifted and appeared to be loose. Additionally, the note reveals concern for a possible infection in the affected toenail, describing the resident's condition as guarded. The resident was medicated with Tylenol (a medication commonly used as a pain reliever) for the symptoms. A wound nurse evaluation and a podiatry consult (a physician who specializes in the treatment of the feet) were recommended.Record review of the Medication Administration Record revealed an order initiated on 8/1/2025 to cleanse the left great toe with normal saline, followed by bacitracin (an antibiotic ointment), and to cover with a dry clean dressing, once a day until resolved. The order was discontinued on 8/4/2025.During a surveyor interview with the resident on 8/6/2025 at 12:42 PM, s/he revealed that his/her toe continues to be painful and has not healed.During a surveyor interview on 8/6/2025 at 1:08 PM with Licensed Practical Nurse, Staff B, she stated that she was unsure if the resident was receiving treatment for his/her left great toe. After reviewing the electronic medical record, she was unable to find an order for a treatment for the toe and stated that she would assess the resident.During a surveyor observation of the resident on 8/6/2025 at 1:24 PM, in the presence of Staff B and the Infection Preventionist (IP) Nurse, revealed the resident's left great toenail was partially detached and the skin surrounding the nail bed was inflamed. The resident lifted the nail up and the nail bed was noted to be inflamed and yellow in color.During a surveyor interview with the IP Nurse immediately following the above observation, she acknowledged that the wound was not resolved and revealed that the treatment order should not have been discontinued.Further review of the progress notes revealed an entry authored by the Assistant Director of Nurses dated 8/6/2025 revealed that NP, Staff A, re-evaluated the wound to the great left toe and provided a new order to reinstate the daily treatment.Record review of a Skin & Wound Evaluation dated 8/6/2025, completed by NP, Staff A, revealed the resident's left dorsum 1st metatarsal joint (the joint on the tip of the toe) nail bed (the soft tissue underneath the toenail) had in house acquired trauma. The wound measurements were noted to be an area of 0.5 centimeters (cm) by 1.5 cm in length and 0.6 cm in width, with redness and inflammation.During a surveyor interview with the Director of Nursing Services on 8/6/2025 at 2:31 PM, she revealed that her expectation would have been that the treatment order for the left great toe would have remained active until the wound was resolved.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from any significant medication errors for 1 of 1 resident reviewed relative to insulin order changes, Resident ID #6.Findings are as follows:Record review revealed Resident ID #6 was admitted to the facility in February of 2020 with diagnosis including, but not limited to, diabetes mellitus (a disease characterized by high blood sugar levels) due to underlying conditions with diabetic neuropathy (nerve damage caused by diabetes), acquired absence of the right leg above the knee, and acquired absence of the left leg below the knee.Record review of a progress note dated 8/5/2025 at 2:35 PM, revealed the resident's labs were reviewed by the Nurse Practitioner (NP), Staff A, new orders were provided to increase the resident's Admelog (a fast-acting insulin used to control blood sugar levels) the evening dose from 14 units to 18 units.Record review revealed a physician's order dated 7/17/2025 for Admelog Injection Solution, 14 units subcutaneously in the evening. Further record review failed to reveal a physician's order relative to the changes made by NP, Staff A on 8/5/2025. This indicates that the order was not updated on 8/5/2025 from 14 to18 units of Admelog for the evening dose.Record review of the resident's Medication Administration Record (MAR) revealed the was administered 14 units of Admelog on 8/5/2025 and 8/6/2025 with his/her evening meal, and not the 18 units as ordered by Staff A.Record review of the resident's blood sugars revealed the following:- On 8/5 at 4:29 PM 420.0 (mg/dL; a normal blood sugar level for diabetics is 80 to 130 mg/dL)- On 8/5 at 7:57 PM 400.0 mg/dLDuring a surveyor interview on 8/7/2025 at 8:33 AM with NP, Staff A, she revealed it was her expectation that the resident would have received the increase dose of Admelog on both 8/5/2025 and 8/6/2025, prior to his/her evening meal, as ordered.During a surveyor interview on 8/7/2025 at 9:32 AM with the Director of Nursing Services (DNS), she acknowledged that the Admelog order failed to be updated until it was brought to her attention by the surveyor. She further acknowledged that the resident missed two doses of the correct insulin dosage.

Based on record review and resident and staff interviews, it has been determined that the facility failed to ensure residents are free from any significant medication errors for 1 of 3 residents reviewed for psychotropic medications, Resident ID #1. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 5/21/2025 indicated a suspected misappropriation of two 0.5 milligram (mg) clonazepam pills for Resident ID #1 from the 11:00 PM - 7:00 AM shift on 5/19/2025 into the 7:00 AM to 3:00 PM shift on 5/20/2025. Review of the Federal Drug Administration's labeling/packet insert for Klonopin (clonazepam, a medication used to treat certain types of seizures and control panic attacks) states in part, .The continued use of benzodiazepines, including Klonopin, may lead to clinically significant physical dependence. The risks of dependence and withdrawal increase with longer treatment duration and higher daily dose. Abrupt discontinuation or rapid dosage reduction of Klonopin after continued use may precipitate acute withdrawal reactions, which can be life-threatening . Review of Resident ID #1's record revealed s/he was admitted to the facility in May of 2024 with diagnoses including, but not limited to, bipolar disorder and major depressive disorder. Record review of a Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 13, indicating the resident is cognitively intact. Record review of physician's orders revealed the resident has been receiving clonazepam tablet 1 milligram (mg) twice a day for anxiety since October of 2024. Additional record review revealed a psychiatric evaluation and consultation follow up document dated 4/23/2025, which stated in part, .Discontinue Clonazapam 1 mg BID [twice daily] for anxiety. Give Clonazapam 0.5 mg BID x 14 days and reassess . Record review revealed two physician's orders, dated 5/2/2025 and 5/13/2025, for clonazepam 0.5 mg oral tablet twice daily for anxiety and to reassess the resident after 5/16/2025. Additional review revealed these orders were discontinued on 5/13/2025 and 5/16/2025. Further review revealed a physician's order dated 5/19/2025 for clonazepam 0.25 mg twice daily. Record review of a progress note dated 5/16/2025 at 8:37 PM states in part, Resident inquired regarding dose of Clonazepam .educated resident the dose being D/C'd (discontinued) due to [him/her] needing to be re-evaluated . During a surveyor interview with Resident ID #1 on 5/28/2025 at 1:15 PM, s/he indicated that the week before s/he did not receive his/her clonazepam for a few days. Additionally, the resident revealed that s/he was feeling more anxious and the shaking of his/her hands had gotten worse. Record review of the May 2025 Medication Administration Record revealed that the resident did not receive any clonazepam from the evening of 5/16/2025 through 5/19/2025. During a surveyor interview with Advanced Practice Registered Nurse (APRN), Staff B, on 5/28/2025 at 3:35 PM she revealed that she was the resident's current psychiatric provider. Additionally, she revealed that the facility staff requested her to meet with Resident ID #1 on 5/20/2025, as s/he was very anxious. Record review revealed a psychiatric evaluation and consultation follow up document dated 5/20/2025, authored by, APRN, Staff B, which states in part, .Physical exam .Nursing reports that this is day two that [s/he] has not had any Klonopin and overall [s/he] is doing OK . During a surveyor interview with the Medical Director on 5/28/2025 at 2:21 PM, she revealed that she was not notified by the facility until 5/19/2025 that the resident had not had any clonazepam since 5/16/2025 and needed an order for it. She indicated that she provided the order for the resident to receive clonazepam 0.25 mg twice daily, as the staff had informed her that the resident was experiencing withdrawal symptoms. Additionally, she revealed that she was aware that the resident was on clonazepam long term and was undergoing a gradual dose reduction (GDR; is the tapering of a dose of medication to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) that was initiated by APRN, Staff C's recommendation on 5/2/2025. However, she was unclear of what Staff C's plan was for the GDR after 5/16/2025 and would have to refer to psychiatry for recommendations. During a surveyor interview with the APRN, Staff C, on 5/29/2025 at 10:29 AM, she revealed that she was previously the psych provider for Resident ID #1 and last saw him/her on 5/7/2025. She indicated that she had recommended a GDR on 4/23/2025 for the resident's clonazepam to be tapered down from 1 mg twice daily to 0.5 mg twice daily for 14 days. Additionally, she revealed she did not follow up with the resident after 5/7/2025 as she was no longer assigned to the resident's facility. Furthermore, she indicated that if she had been able to reassess the resident following the reduction of the resident's clonazepam, her plan was for the resident to remain on 0.5 mg of clonazepam twice a day. Furthermore, she revealed that the clonazepam should not be abruptly stopped because of the potential of dangerous withdrawal symptoms of that medication. During a surveyor interview with the Director of Nursing in the presence of the Administrator on 5/29/2025 at 12:33 PM, she was unable to provide evidence that the resident remained free of any significant medication errors due to the significant medication being abruptly discontinued without an appropriate GDR.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to following physician's orders for 1 of 1 resident reviewed with parameters for weights, Resident ID #2. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing page 314, states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review revealed Resident ID #2 was readmitted to the facility in July of 2024 with a diagnosis including, but not limited to, congestive heart failure (a condition where the heart is unable to pump blood effectively). Record review revealed a physician's order dated 12/12/2024 to notify the provider for a weight greater than 200 pounds. Record review of the January 2025 vital signs report revealed that the resident's weight was greater than 200 pounds on the following dates: - 1/8/2025 - 1/19/2025 Additional record review failed to reveal evidence that the provider was notified that the resident's weights were greater than 200 pounds, as ordered, on 1/8/2025 and 1/19/2025. During a surveyor interview on 1/22/2025 at 2:46 PM, with the Nurse Practitioner, she revealed that she was not made aware of the resident's weights on 1/8/2025 and 1/19/2025. During a surveyor interview on 1/22/2025 at approximately 3:00 PM, with the Director of Nursing Services, she was unable to provide evidence that the physician's order was followed.

Based on record review and staff interview, it has been determined that the facility failed to accurately document in the resident's medical record for 3 of 4 residents reviewed for weekly skin checks, Resident ID #s 2, 3 and 4. Findings are as follows: Review of a facility policy titled Risk and Skin Assessments states in part, Prevention of pressure ulcers requires early identification of at-risk residents and implementation of prevention strategies .weekly skin checks [skin assessment] should be done by a licensed nurse weekly . 1. Record review revealed Resident ID #2 was readmitted to the facility in July of 2024 with a diagnosis including, but not limited to, chronic obstructive pulmonary disease (COPD- a lung disease characterized by airflow limitation). Record review revealed a physician's order dated 11/18/2024, indicating a weekly skin assessment should be completed using a user-defined assessment (UDA, a monitoring tool the facility uses for skin assessments). Record review of the November, December 2024 and January 2025 Medication Administration Records (MAR) revealed that the skin evaluation and UDA was documented as completed on the following dates: - 11/15/2024 - 12/2/2024 - 12/9/2024 - 12/16/2024 - 12/23/2024 - 12/30/2024 - 1/6/2025 - 1/13/2025 - 1/20/2025 Additional record review failed to reveal evidence that the UDAs were completed on the dates listed above. 2. Record review revealed Resident ID #3 was admitted to the facility in January of 2025, with a diagnosis including, but not limited to, obesity. Record review revealed a physician's order dated 11/14/2024, indicating a weekly skin evaluation should be completed using a UDA. Record review of the January 2025 MAR revealed that the skin assessment and UDA were documented as completed on 1/21/2025. Additional record review failed to reveal evidence that the UDA was completed on 1/21/2025. 3. Record review revealed Resident ID #4 was admitted to the facility in October of 2024, with a diagnosis including, but not limited to, diabetes. Record review revealed a physician's order with a start date of 7/3/2024, indicating a weekly skin assessment should be completed using a UDA. Record review of the January 2025 MAR revealed that the skin assessment and UDA were documented as completed on 1/10/2025. Additional record review failed to reveal evidence that the UDA was completed on 1/10/2025. During a surveyor interview on 1/22/2025 at approximately 10:00 AM with the Director of Nursing Services she was unable to provide evidence that the above-mentioned residents' UDAs were accurately documented in the medical records.

Based on record review and staff interview, it has been determined that the facility failed to protect the residents' right to be free from abuse for 2 of 2 residents reviewed who sustained injuries as a result of a resident-to-resident altercation, Resident ID #s 1 and 3. Findings are as follows: Review of a facility policy titled, Abuse, last revised October of 2022 states in part, .The facility prohibits the .abuse of residents .by anyone .Definitions Abuse: The willful infliction of injury .or punishment resulting physical harm, pain or mental anguish .to residents .Physical abuse Includes hitting, slapping . 1. Record review of a community reported complaint submitted to the Rhode Island Department of Health on 9/25/2024 indicates that Resident ID #1 (the victim) alleged that the Skilled Nursing Facility was aware that s/he had been threatened by Resident ID #2 (the perpetrator), resulting in Resident ID #1 being assaulted by Resident ID #2. Record review revealed that Resident ID #1 was admitted to the facility in September of 2024 with a diagnosis including, but not limited to, chronic multifocal osteomyelitis (bone infection) of the right ankle and foot, anxiety disorder and chronic post-traumatic stress disorder (PTSD). Review of Resident ID #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact condition. Record review of Resident ID #1's care plan revealed a focus area initiated on 9/26/2024 indicating the resident was a victim of a recent traumatic event related to his/her diagnosis of PTSD, with interventions including but not limited to maintaining a safe environment for his/her safety. Record review of a progress note dated 10/14/2024 at 8:15 PM revealed a skin check was authored by Registered Nurse (RN), Staff A, which indicated that Resident ID #1 did not have any bruises or redness to his/her face or neck. Further review of the progress notes dated 10/14/2024 at 8:59 PM authored by RN, Staff B, revealed that Resident ID #1 accused Resident ID #2 of hitting him/her with a commode cover on the head and face and requested to be seen at the hospital. Record review of an Emergency Department (ED) provider note dated 10/14/2024 at 9:50 PM revealed that Resident ID #1 presented to the hospital after reportedly being a victim of an assault. S/he reports that s/he was in his/her room and was assaulted by another resident who previously verbally abused her/him. Further review of the ED provider note revealed that the resident had a Computed Tomography (CT; a test that uses special x-ray equipment to help assess injuries) of the brain, face, and cervical spine that resulted positive for a nondisplaced right maxillary bone (right upper jaw) fracture involving lateral wall of right maxillary sinus (area near the side of the nose). Record review revealed that, Resident ID #2, was admitted to the facility in April of 2024 with diagnoses including, but not limited to, dementia with behavioral disturbance with behavioral disturbance. Record review of a psychiatric evaluation and consultation note dated 10/7/2024 revealed that nursing staff requested this consultation because of Resident ID #2's behavior. In addition, it revealed a current assessment/plan that indicated, in part, to monitor his/her mood for behavior changes or concerns, give medications as ordered and to continue with the plan of care. Record review of Resident ID #2's care plan initiated on 5/2/2024 revealed a focus area for behavioral problems related to agitation that includes in part, yelling, wandering into other resident's rooms, taking their belongings, history of homicidal ideation and striking out against staff and residents. Interventions include in part, to provide one on one care when needed for periods of agitation, and restlessness. During a surveyor interview on 10/18/2024 at 12:15 PM with Nursing Assistant (NA), Staff D, revealed that Resident ID #2 walks around the unit aimlessly and enters other residents' rooms taking their belongings. She then described Resident ID #2 as being out of control. In addition, Staff D states that Resident ID #2 requires two staff for care and that s/he is sometimes physically aggressive toward staff and would slap or scratch when while they are providing care. She further revealed that Resident ID #2 will take other residents' belongings when she/he wanders into other residents room and then attempts to slap other residents when they try to get their belongings back. Record review of a progress notes dated 10/15/2024 revealed the following: - 12:28 AM: Resident ID #2 was accused by another resident of hitting him/her on the head with a commode cover. Resident ID #2 was interviewed by two police officers but was unable to tell the story due to his/her dementia. - 9:42 PM: Resident ID #2 was sent out to the hospital for evaluation secondary to having a physical altercation with another resident in addition to having increased wandering behaviors including going into other residents' rooms. During a surveyor interview on 10/21/2024 at 1:30 PM with the Director of Nursing Services (DNS), she revealed that Resident ID #2 is not an appropriate candidate for this facility and that s/he should be in a memory care unit. Additionally, she acknowledged that that Resident ID #1 was not kept free from physical abuse. During a surveyor interview on 10/21/2024 at approximately 2:30 PM with the Administrator she acknowledged that Resident ID #1 was not kept free from physical abuse. 2. Record review of a facility reported incident submitted to the Rhode Island Department of Health on 9/20/2024 alleges that (the perpetrator) Resident ID #4 entered (the victim's) Resident ID #3's room. Resident ID #3 attempted to redirect Resident ID #4 out of his/her room and Resident ID #4 refused to leave. Staff E, NA, heard the altercation and went to the room and separated the residents. Resident ID #3 was assessed, and a skin tear was noted on his/her lower lip. Record review revealed that Resident ID #3 was admitted to the facility in October of 2019 with a diagnosis including, but not limited to, multiple sclerosis (a chronic autoimmune disease that damages the central nervous system) and anxiety disorder. Review of Resident ID #3 's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating intact condition. Record review of a progress note dated 9/20/2024 at 11:37 PM authored by Licensed Practical Nurse (LPN), Staff F, revealed that at around 9:30 PM, Resident ID #s 3 and 4 were involved in an altercation, which resulted in Resident ID #3 sustaining a bloody lip. Record review revealed that Resident ID #4 was admitted to the facility in September of 2024 with diagnoses including, but not limited to, dementia and delusional disorder. Review of Resident ID #4's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15, indicating moderately impaired cognition. Record review of a care plan revised on 9/23/2024 revealed a focus area for behavior problem related to impulsive behavior that includes in part, difficult to redirect, increased aggression, taking food from other's trays, wandering behavior, displayed aggressive behaviors towards others related striking another resident. The interventions include but are not limited to providing a program of activities. Record review of a progress notes dated 9/20/2024 at 11:41 PM authored by Staff F, revealed that Resident ID #4 had an altercation with another resident and was removed from his/her room and was transferred to the hospital for a psychiatric evaluation. Record review of a hospital discharge summary dated 9/21/2023 revealed that the resident was sent out to the hospital after punching another resident. Additionally, it revealed that the resident had been intermittently aggressive towards residents and staff in the facility. During a surveyor interview on 10/21/2024 at approximately 1:30 PM with the DNS, she acknowledged that that Resident ID #3 was not kept free from physical abuse and sustained an injury to his/her lip as a result of the altercation.

Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for blood pressure medications with parameters, Resident ID #80. 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. Record review revealed the resident was readmitted to the facility in August of 2023 with a diagnosis including, but not limited to, pulmonary hypertension (a condition in which high blood pressure affects arteries of the lungs and the right side of the heart). Record review revealed a physician order with a start date of 8/6/2023, for Isosorbide Mononitrate (a medication that is used to treat high blood pressure), with instructions to administer 60 milligrams (mg) once daily and hold if the systolic blood pressure (SBP; pressure when the heart beats) is less than 110. Record review of the Medication Administration Record and the vital sign summary report for July 2024 failed to reveal evidence that the resident's blood pressure was obtained for 30 out of 30 opportunities, prior to administering the Isosorbide Mononitrate medication, per the physician order. Further review revealed a physician order, with a start date of 8/6/2023, for Hydralazine (a medication that is used to treat high blood pressure), with instructions to administer 25 mg, three times a day, and hold if the SBP is less than 110. Record review of the Medication Administration Record and the vital sign summary report for July 2024 failed to reveal evidence that the resident's blood pressure was obtained for 60 out of 90 opportunities, prior to administering the Hydralazine, per the physician order. During a surveyor interview on 7/31/2024 at 11:28 AM, with the Director of Nursing Services, she indicated that she would expect staff to obtain and document the residents blood pressure, prior to administering medication. Additionally, she was unable to provide evidence that the resident's blood pressure was monitored, and the medications were not administered to the resident unnecessarily.

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 3 residents reviewed relative to Multi-drug Resistant Organisms (MDRO), Resident ID #30 and 1 of 1 resident reviewed for an indwelling catheter (a flexible tube inserted into the bladder to drain urine), Resident ID #91. Findings are as follows: 1. Review of the Center for Disease Control and Prevention (CDC) policy titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug resistant Organisms (MDROs) last updated 7/12/2022 revealed in part, .Enhanced Barrier Precautions [EBP] 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 [gown and glove upon entering the room] do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization [the bacteria is living on or in the body not causing symptoms but can the bacteria can be spread to others] as well as for residents with MDRO infection or colonization .Summary of Personal Protective Equipment (PPE) Use and Room Restriction When Caring for Residents in Nursing Homes .Enhanced Barrier Precautions .All residents with any of the following .Infection or colonization with an MDRO when Contact Precautions do not otherwise apply . Review of a facility policy titled Enhanced Barrier Precautions states in part, .for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO that is not currently targeted by CDC, the facility may consider placing residents with known MDRO colonization on EBP to control MDRO transmission, if Contact Precautions do not apply. Epidemiological important MDROs (that are not target by the CDC) may include, but are not limited to, .ESBL [Extended-spectrum beta-lactamase] . Record review revealed Resident ID #30 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, dementia and type 2 diabetes mellitus. Record review revealed that the resident tested positive for ESBL on 3/5/2024 at the facility. Record review revealed a care plan dated 3/8/2024 last revised on 4/11/2024 revealed that the resident has a history of ESBL with an intervention that includes, but is not limited to, Contact Precautions. Surveyor observations on 7/29, 7/30, 7/31 and 8/1/2024 failed to reveal evidence that the resident was on Contact or Enhanced Barrier Precautions relative to the diagnosis of a MDRO, per the facility policy, care plan, and/or the CDC. During a surveyor interview on 8/1/2024 at 9:57 AM with the Director of Nursing Services (DNS) in the presence of the Administrator, she acknowledged that the resident was positive for ESBL in March of 2024 and that the resident was not on precautions at this time. She further revealed that the resident will now be placed on Enhanced Barrier Precautions. 2. Review of a policy titled, Catheter Guidelines states in part, .If breaks in aseptic (clean) technique, disconnection, or leakage occurs, replace the catheter and collecting system using aseptic technique and sterile equipment as ordered .Infection Control .Be sure the catheter tubing and drainage bag are kept off the floor . Record review revealed that Resident ID #91 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, type 2 diabetes and dementia. Record review revealed that the resident has an indwelling catheter. Record review revealed a physicians order dated 3/2/2024 to change the residents urinary drainage bag if the bag is soiled, broken, or leaking. Record review revealed a care plan dated 5/15/2024 last revised on 7/23/2024 which revealed that the resident has an indwelling catheter with an intervention to keep the urinary collection bag off the floor. Surveyor observations on the following dates and times revealed that the urinary collection bag was on the floor: -7/29/2024 at 11:39 AM -7/31/2024 at 9:49 AM -7/31/2024 at 9:58 AM During a surveyor interview and subsequent observation with Registered Nurse, Unit Manager, Staff B on 7/31/2024 at 9:58 AM, she acknowledged that the urinary collection bag was on the floor leaking urine which formed a puddle. Staff B revealed that the collection bag should not be stored on the floor and it should not be not leaking. Review of the Medication Administration Record failed to reveal evidence that the urinary drainage bag was changed after being on the floor or leaking. During a surveyor interview with the DNS on 8/1/2024 at approximately 9:45 AM she revealed that the urinary drainage bag should be changed and should not be left on the floor per the facility policy and the care plan. Additionally, after this concern was identified and brought to the facility's attention, the urinary drainage bag was again noted to be on the floor on 8/1/2024 at 11:46 AM. 47939

Based on record review and staff interview, it has been determined that the facility failed to ensure the resident's medical record includes documentation that the resident either received the pneumococcal vaccination or did not receive the vaccination due to medical contraindications or refusal, for 4 of 7 residents reviewed, Residents ID #s 17, 63, 73, and 106. Findings are follows: According to the Centers for Disease Control and Prevention (CDC), pneumococcal vaccination for all adults 19 through [AGE] years old who have certain chronic medical conditions or [AGE] years or older who have only received PPSV23 [type of pneumococcal conjugate vaccination], the PVC15 [type of pneumococcal conjugate vaccine] or PVC20 [type of pneumococcal conjugate vaccine] dose should be administered at least one year after the most recent PPSV23 vaccination. For adults 19 through [AGE] years old who have certain chronic medical indications who have only received PVC13 [type of pneumococcal conjugate vaccine], give 1 dose of the PCV20 at least 1 year after PCV13 or give 1 dose of PPSV23 at least 8 weeks after PCV13. For adults [AGE] years or older who have only received PVC13, give PPSV23 or PCV20 as previously recommended. 1. Record review for Resident ID #17 revealed the resident was readmitted to the facility in January of 2020. Record review of the resident's immunization records failed to reveal evidence that the PVC15, PVC13, or PCV20 was offered, received, or declined. 2. Record review for Resident ID #63 revealed the resident was readmitted to the facility in December of 2022. Record review of the resident's immunization records failed to reveal evidence that the PVC15, PVC13, or PCV20 was offered, received, or declined. 3. Record review for Resident ID #73 revealed the resident was readmitted to the facility in January of 2024. Record review of the resident's immunization records failed to reveal evidence that the PVC13, PCV15, PPSV23, or PCV20 was offered, received, or declined. 4. Record review for Resident ID #106 revealed the resident was readmitted to the facility in May of 2023. Record review of the resident's immunization records failed to reveal evidence that the PVC13, PCV15, PPSV23 or PCV20 was offered, received, or declined. During an interview on 8/1/2024 at 10:57 AM , with the Director of Nursing Services, she was unable to provide evidence that Residents ID #s 17, 63, 73 and 106 medical records included documentation that indicates, at a minimum, if the residents either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal, until brought to the attention of the facility by the surveyor.

Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 1 resident reviewed for tracheostomy (trach; an opening that surgeons make through the front of the neck and into the windpipe. A tube is placed into the opening for breathing) suctioning, Resident ID #114. Findings are as follows: Review of a facility policy titled, Tracheostomy Care revealed in part, .Tracheostomy care has identical goals: to ensure airway patency by keeping the tube free of mucus buildup, to maintain mucous membrane and skin integrity, to prevent infection .Check physician order . Record review revealed Resident ID #114 was readmitted to the facility in October of 2023 with diagnoses including, but not limited to, acute respiratory failure with hypoxia (low level of oxygen), history of malignant Neoplasm of the larynx (cancer of an organ in the neck that forms an air passage to the lungs). Further record review revealed the resident has a tracheostomy. Review of the physician's orders revealed the following: 10/13/2023- Suction trach using a single-use suction catheter and suction kit as needed for excessive secretions and airway maintenance. Record review failed to reveal evidence of when to change, clean, or replace the suction equipment. It further failed to reveal evidence of a current order for the resident to perform the suctioning themselves. Further record review failed to reveal evidence that the resident was assessed as being safe to self suction following readmission to the facility in October of 2023. During a surveyor observation and interview on 7/31/2024 at 10:51 AM with the resident in his/her room revealed a suction machine with the canister filled to 350 cc (cubic centimeter) of secretions with floating sediment. The canister and the attached tubing were undated. The resident stated that s/he suctions his/her own trach. During a surveyor interview with Registered Nurse, Staff A, on 7/31/2024 at 10:55 AM, she revealed that the resident does suction the trach him/herself. She acknowledged that there was no date on the suction machine tubing or canister. Additionally, she was unable to provide evidence of when the canister was emptied last or changed. During a surveyor interview with the Registered Nurse, Unit Manager, Staff B, on 7/31/2024 at 11:04 AM, she acknowledged that the tubing and canister on the suction machine should be dated and was unable to provide evidence of when the canister was last emptied or changed. Additionally, she could not provide a current order for the resident to self-suction his/her trach, although she revealed that the resident has been doing it for months. During a surveyor interview with the Director of Nursing Services, on 7/31/2024 at 11:32 AM, she was unable to provide evidence of a current physician order allowing the resident to self-suction, an assessment for safety following readmission, or an order of when to change, clean, or replace the suction equipment.

Based on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic for 2 of 2 residents reviewed for antibiotic use, Resident ID #s 17 and 54. Findings are as follows: According to the Centers for Disease Control and Prevention (CDC) document titled, The Core Elements of Antibiotic Stewardship for Nursing Homes states in part, Standardize the practices which should be applied during the care of any resident suspected of an infection or started on an antibiotic. These practices include improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, optimizing the use of diagnostic testing, and implementing an antibiotic review process, also known as an antibiotic time-out, for all antibiotics prescribed in your facility. Antibiotic reviews provide clinicians with an opportunity to reassess the ongoing need for and choice of an antibiotic when the clinical picture is clearer and more information is available .Track the amount of antibiotic used in your nursing home to review patterns of use and determine the impact of new stewardship interventions .Interventions designed to shorten the duration of antibiotic courses, or discontinue antibiotics based on post-prescription review (i.e., antibiotic time-out), may not necessarily change the rate of antibiotic starts, but would decrease the antibiotic DOT [days of therapy] . Review of the facility's Quality Assurance and Performance Improvement (QAPI) plan revealed the data collection for infection control and antibiotic stewardship information is collected on a weekly basis. 1. Record review revealed that Resident ID #17 was readmitted to the facility in January of 2020 with diagnoses including, but not limited to, Chronic Obstructive Pulmonary Disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and bipolar disorder. Record review revealed a physician's order for Amoxicillin (an antibiotic) 500 milligram (mg) capsule every eight hours for a tooth extraction for 21 days with a start date of 7/11/2024 and an end date of 8/1/2024. Record review failed to reveal evidence that the facility implemented an antibiotic review process to determine if the antibiotic is still indicated or adjustments should be made. Review of the facility provided infection control and antibiotic stewardship program tracking tool failed to reveal evidence of tracking antibiotic use for the month of July 2024 including, but not limited to, Resident ID #17. 2. Record review revealed that Resident ID #54 was admitted to the facility in June of 2024 with diagnoses including, but not limited to, hematuria (blood in urine) and anxiety disorder. Record review revealed a physician's order for Cipro oral tablet 250 mg by mouth two times a day for a urinary tract infection for 5 Days with a start date of 7/29/2024. Record review failed to reveal evidence that the facility implemented an antibiotic review process, to determine if the antibiotic is still indicated or adjustments should be made. Review of the facility provided infection control and antibiotic stewardship program tracking tool failed to reveal evidence of tracking antibiotic use for the month of July 2024 including, but not limited to, Resident Id #54. During a surveyor interview on 7/31/2024 at 11:20 AM with the Director of Nursing Services (DNS), she revealed that the facility utilizes an infection control and antibiotic stewardship program tracking tool to review antibiotics. During this interview and subsequent record review, revealed that the month of July's antibiotic tracker was empty. The DNS further revealed that the tracker is filled out at the end of the month. Additionally, she was unable to provide evidence of antibiotic reviews for the month of July or that tracking and trending were being completed. During a surveyor interview with the DNS and the Administrator on 8/1/2024 at 9:29 AM, they revealed that they completed the tracker for the month of July after it was brought to their attention by the surveyor. Additionally, they were unable to provide evidence that the antibiotic stewardship tracking system was completed to its entirety, per regulation.

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 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of a community reported complaint sent to the Rhode Island Department of Health on 11/19/2023 alleges that Resident ID #1 was not given his/her methadone or klonopin medications for 72 hours due to the facility not having either available to administer. Record review revealed that the resident was admitted to the facility on [DATE] with diagnoses which include, but are not limited to, opioid abuse in remission, obstructive sleep apnea (when one's breathing is interrupted during sleep), and cancer of the kidney. Record review revealed the following physician's orders: -11/17/2023 Klonopin 0.5 MG (milligram) give 1 tablet by mouth one time a day for anxiety -11/17/2023 Klonopin 1 MG give 1 tablet by mouth at bedtime for anxiety -11/17/2023 Methadone HCI oral concentrate 10 MG/ML, give 100 MG by mouth in the morning for pain Record review of the November 2023 Medication Administration Record (MAR) failed to reveal evidence that the resident received the above-mentioned medications, as ordered, on the following dates and times: -11/17/2023 at 6:00 AM Methadone 100 MG -11/17/2023 at 7:00 AM to 2:00 PM Klonopin 0.5 MG -11/17/2023 at 6:00 PM to 10:00 PM Klonopin 1 MG -11/18/2023 at 6:00 AM Methadone 100 MG -11/18/2023 at 7:00 AM - 2:00 PM Klonopin 0.5 MG Record review of a progress note dated 11/17/2023 at 11:23 PM revealed in part Resident a/o [alert and oriented] x 3 [to person, place and time], behavior noted on shift screaming [s/he] wants [his/her] methadone and throwing objects from bedside table to the floor, explained that [his/her] methadone will probably be delivered tomorrow morning by [pharmacy name redacted] . Further review of the progress note revealed that the Klonopin 1 MG not delivered by pharmacy, pharmacy has not received the script . Record review of the facility document titled SNF/NH to hospital transfer form dated 11/18/2023 at 3:00 PM revealed that the resident was transferred to a hospital. Record review of the resident's hospital documentation revealed the following: -11/18/2023 at 6:40 PM, Pt [patient] from [facility] with reports from facility of agitation, crying and requesting to go to ED [emergency department]. Pt is on 100 mg methadone, last dose was 11/16. Reports facial numbness for past few days . -11/18/2023 at 7:11 PM, .presents from [facility] with concerns for methadone withdrawal. Patient was recently discharged for an acute CVA [stroke] with subsequent blindness and left upper extremity weakness as a sequalae, was hospitalized for 1 week, was discharged to [facility] Patient states since that time [s/he] has not received [his/her] methadone which is up in approximately 72 hours, [s/he] started to develop full body aches, and feeling ill . -11/18/2023 at 7:30 PM, .[resident] presents from .[facility] with concerns for acute methadone withdrawal, inability to obtain [his/her] methadone for the last 72 hours since discharged from [hospital] . During a surveyor interview on 11/21/2023 at 11:50 AM with Licensed Practical Nurse (LPN), Staff A, she revealed that the resident was admitted on [DATE] and was transferred to the hospital on 11/18/2023. She further indicated that prior to his/her admission on 11/16/2023, she had received a telephone call from the hospital's Neuro Unit on 11/14/2023 because the resident was supposed to be transferred to the facility that day and the hospital was concerned that the methadone would not be available for the resident when s/he arrived at the facility. She further revealed that because of that telephone call the resident's admission was delayed to 11/16/2023. Additionally, Staff A revealed that on 11/17/2023 the resident's Attending Physician assigned to him/her while in the facility, provided orders for the resident for the Klonopin but s/he never received the medication. During a surveyor interview on 11/22/2023 at 9:07 AM with LPN, Nurse Manager, Staff B, he revealed that it was not until after the resident missed two doses of his/her methadone and s/he was transferred to the hospital that the facility followed up on the delivery status of the methadone, with the methadone clinic that the order had been faxed to. Additionally, he revealed that when the facility initially faxed the order to the methadone clinic it was to the incorrect clinic, which is why the resident's methadone was never delivered to the facility. He further revealed that it was not until after the resident was transferred to the hospital when the facility realized their error and placed a follow-up telephone call to the methadone clinic to inquire about the delivery status of the medication. During a surveyor interview on 11/21/2023 at 1:00 PM with the Director of Nursing Services, she acknowledged that the resident did not receive Methadone or Klonopin, as ordered, while in the facility. Additionally, she revealed that the Klonopin prescription was never filled by the facility's pharmacy because the pharmacy never received the prescription from the Attending Physician for the medication. On 11/21/2023 and on 11/22/2023 the surveyor attempted to interview the Attending Physician via telephone to inquire as to the reason he ordered Klonopin for the resident and evidence the prescription was sent to the pharmacy; however, he did not answer his phone, voice mails were left for him, but the calls were not returned to the surveyor.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that the resident receives adequate supervision to prevent elopements, for 1 of 8 sample residents reviewed, Resident ID #1. Findings are as follows: Review of the facility's policy titled, Elopement Prevention, which was last revised in February 2020, states, in part .the facility strives to promote resident safety .the facility maintains a process to assess all residents and institute measures for resident identification at the time of admission .the physical plant is secured to minimize the risk of elopement such as safety locks or key-pad entry that restrict access to dangerous areas .locking main entrance to building with designated 'unlocked' times when the door can be monitored continuously, i.e. security/receptionist . Record review reveals that Resident ID #1 was admitted to the facility in June 2023 with diagnoses including, but not limited to, major neurocognitive disorder (a disorder characterized by a significant decline in at least one of the domains of cognition which include executive function, complex attention, language, learning, memory, perceptual-motor, or social cognition) cognitive communication deficit (difficulty with thinking and how someone uses language), anxiety disorder, CVA (stroke), major depressive disorder without psychotic features, blindness of right eye, and hypertension (high blood pressure). Additional record review revealed Resident ID #1 was admitted to the 4th floor which requires a keypad entry for elevator and stairwell access. Record review of the Minimum Data assessment dated [DATE] revealed a Brief Interview of Mental Status score of 4 out of 15, indicating the resident has severely impaired cognition. Review of hospital records revealed a Saint [NAME] University Mental Status Exam (SLUMS) was completed during the resident's hospitalization with a score of 6 out of 30 indicating a possible significant neurocognitive disorder. The SLUMS assessment is provided to patients with diagnoses of dementia to test attention, immediate recall, orientation, delayed recall, numeric calculation, visuospatial, executive function, and extrapolation. Additional review of the hospital records revealed the resident was admitted to the geriatric psychiatric unit for further evaluation including management of his/her functional decline. Hospital records state in part .the patient may benefit from an environment with 24-hour supervision to address patient's current memory and cognitive deficits, such as a nursing home and provide maintenance of safe living environment for optimal function .Judgement: impaired (inability to care for self at home) .Mood: sad / depressed / anxious / worried .Affect: depressed / constricted . During a surveyor interview on 6/19/2023 at approximately 12:30 PM with both the Administrator and Director of Nursing Services (DNS), they revealed that on 6/17/2023 Resident ID #1 had eloped from the facility via the front door. Additionally they revealed that s/he was exiting the building with other visitors. They further revealed that during the second shift, the charge nurse, Licensed Practical Nurse (LPN), Staff B, discovered the resident was not in the facility during a medication pass. A search for the resident was initiated and s/he was not found. Therefore, a code gray (alert of a missing elderly person) was initiated, and the police were notified. During a surveyor interview on 6/20/2023 at 3:12 PM with Staff B, she revealed that she had worked a double shift on 6/17/2023 from the hours of 7:00 AM to 11:00 PM. She further revealed that when she went to change the medication administration record (MAR) in the computer from first shift to second, she saw photographs of all residents who were due for medication which included Resident ID #1. Staff B indicated that she and other staff searched the entire unit including resident rooms, all floors, stair wells and outdoor grounds and was unable to locate the resident. Therefore, a code gray was initiated, and the police were notified. Review of the facility camera footage for 6/17/2023 revealed Resident ID #1 walked out of the front entry door at 4:36 PM alone. Additionally, the camera footage revealed that the the receptionist, who is responsible for monitoring who enters and leaves the facility, as well as unlocking the door via a buzzer, allowed the resident to exit the facility without verifying his/her identity. Record review of the facility's policy titled, Visitation, which was last revised in December 2019, states, in part .all visitors are required to sign into Facility's visitor log upon arrival and sign out prior to leaving . During an interview on 6/20/2023 at 12:10 PM with receptionist, Staff A, she revealed that she worked on 6/17/2023 from 4:00 PM to 12:00 AM. She further indicated that she buzzed the alarm which activated the front door to open and led to Resident ID #1 exiting the facility. Additionally, Staff A revealed that she did not know the resident as she had not seen him/her before and thought s/he was a visitor. Staff A revealed that visitors normally sign in/out of the visitor book, and she did not ask Resident ID #1 to sign out of the visitor book before she allowed him/her to exit the facility. Record review of a police report indicates that the police were dispatched on 6/18/2023 at approximately 9:30 PM to the resident's location, where s/he was found sitting down on the sidewalk. The resident was noted to be alert and awake but oriented to person only. The resident was noted to be hypertensive with a blood pressure reading of 142/110, (a normal blood pressure reading is 120/80), and indicated s/he had a history of dementia. Additional review of the police report revealed the resident had a bracelet on with contact information for the facility, and they called [NAME] Center who informed them that the resident eloped the day before. The resident was then transferred to an acute care hospital for a medical evaluation. During an interview on 6/21/2023 at approximately 1:40 PM with the Administrator and DNS, they revealed it is their expectation that the person sitting at the receptionist desk would verify every person's identity prior to opening the door and allowing them to leave the facility. Additionally, they were unable to provide evidence that Resident ID #1 received adequate supervision to prevent him/her from eloping from the facility on 6/17/2023. Based on the above, the facility failed to promote safety for Resident ID #1 who successfully eloped from the facility due to a lack of supervision and monitoring which placed him/her in immediate jeopardy. 46671

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide services to attain and maintain the highest practicable physical, mental, and psychosocial wellbeing for 1 of 8 sample residents reviewed, Resident ID #1. Findings are as follows: Review of a Continuity of Care form from an acute care hospital dated 5/24/2023, revealed that Resident ID #1 was brought to the Emergency Department (ED) by Emergency Medical Services (EMS) with reported behavior, including but not limited to, having unkempt living conditions, inability to manage daily tasks including properly self-medicating. In addition, hospital records indicate that the resident lost his/her spouse who was his/her primary caregiver and was evicted from his/her home due to non-payment and poor living conditions. Further review of hospital records revealed Resident ID #1 had reported feeling depressed, and hopeless. In addition, the hospital records revealed the resident was admitted to the geriatric psychiatric unit for further evaluation and management of functional decline. Of note, Resident ID #1 was admitted on an involuntary legal status for worsening depression, and inability to care for his/her self in the context of psychosocial stressors, questionable substance abuse and treatment noncompliance. The hospital records state in part .the patient may benefit from an environment with 24-hour supervision to address patient's current memory and cognitive deficits, such as nursing home and provide maintenance of safe living environment for optimal function .Judgement: impaired (inability to care for self at home) .Mood: sad/depressed/anxious/worried .Affect; depressed/constricted . Review of a preadmission screening and resident review (PASSR) (a comprehensive evaluation necessary to confirm the indicated diagnosis and to determine whether placement or continued stay in a Nursing facility is appropriate), which was completed by the Rhode Island Department of Mental Health Division of Behavioral Healthcare Services on 6/6/2023, states in part .assist with adjustment to the nursing facility . Resident ID #1 was admitted to the facility in June of 2023 with diagnoses including, but not limited to, major neurocognitive disorder (a disorder categorized by a significant decline in at least one of the domains of cognition which include executive function, complex attention, language, learning, memory, perceptual-motor, or social cognition), major depressive disorder without psychotic features, and anxiety disorder. Record review of the Minimum Data assessment dated [DATE], revealed a Brief Interview of Mental Status score of 4 out of 15, indicating the resident has severely impaired cognition. Additionally, the Patient Health Questionnaire (PHQ-9) which is used for screening, diagnosing, monitoring, and measuring the severity of depression and detection of anxiety symptoms revealed a score of 3 out of 27, indicating minimal depression. Review of a policy titled,Admission-Readmission, which was last revised in September 2022, states, in part .the objectives for our admission/readmission policies are to admit residents who can be adequately cared for by the facility .assure that the facility receives appropriate medical and financial records prior to or upon the resident's admission .nursing is responsible for the clinical review and to determine, if any specialized equipment or medications are needed .the pre-admission process includes obtaining documents that include, but are not limited to, past medical history and psychological background . Review of a [Social Service Assessment and Documentation-V3] dated, 6/8/2023, indicates that Resident ID #1 has a diagnosis of a major mental illness as evidenced by question 1a.Does the patient/resident have a diagnosis of a major mental illness, being checked off as yes. During an interview on 6/21/2023 at approximately 11:25 AM with the Social Services Director, Staff C, she revealed that her standard of practice and expectation for social services is to refer all new admissions, regardless of diagnosis, to psych services for an evaluation secondary to being new to the facility and possibly having adjustment issues. Staff C revealed that onsite psychiatric services are provided at the facility. Staff C further indicated that a nurse practitioner and a licensed clinical social worker that provide the onsite psychiatric services are at the facility every week. Review of a document titled, [Behavioral Health Visit Request/Follow-Up] revealed Resident ID #1 is listed on the document that is dated 6/8/2023. Reason for this Request states in part .new admission, dx (Diagnosis) MDD (Moderate Depressive Disorder) and Anxiety d/o (Disorder) . Review of Resident ID #1's medical record revealed that the facility was aware of his/her history pertaining to a psychiatric hospitalization and the course of treatment that was provided to him/her. Record review of a police report indicates that the police were dispatched on 6/18/2023 at approximately 9:30 PM to the resident's location, where s/he was found sitting down on the sidewalk. The resident was noted to be alert and awake but oriented to person only. The resident was noted to be hypertensive with a blood pressure reading of 142/110, (a normal blood pressure reading is 120/80), and indicated s/he had a history of dementia. Additional review of the police report revealed the resident had a bracelet on with contact information for the facility, and they called [NAME] Center who informed them that the resident eloped the day before. The resident was then transferred to an acute care hospital for a medical evaluation. Record review failed to reveal evidence that Resident ID #1 had received psych services until 6/20/2023, after s/he successfully eloped from the facility. Of note, the psychiatric evaluation dated 6/20/2023, states in part . initial psychiatric evaluation .[s/he] recently eloped from the facility but does not remember .reports feelings of sadness, hopelessness, fatigue, and anhedonia [an inability to experience pleasure from activities usually found enjoyable] .would benefit from supportive therapy .will follow up routinely or as needed . During an interview on 6/21/2023 at approximately 12:45 PM with Staff C, she was unable to explain why Resident ID #1 had not been seen by psych services until 6/20/2023, when s/he had been on the referral list since 6/8/2023. Additionally, Staff C was unable to provide evidence that services were provided to Resident ID #1 to attain and maintain his/her highest practicable physical, mental, and psychosocial wellbeing.

Based on record review and staff interview it has been determined that the facility failed to provide basic life support, including Cardiopulmonary Resuscitation (CPR), to a resident requiring such emergency care prior to the arrival of emergency medical personnel, subject to related physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings are as follows: Review of the record revealed this resident was admitted to the facility in July of 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the [DATE] progress notes, written by Nurse Staff D, revealed in part: - [DATE] at 8:43 AM: Resident sent out to [hospital name redacted] by rescue, resident had vomited, change in mental, LS [lung sounds] bubbling on the left and right upper lobes and unresponsive by the time rescue arrived . - [DATE] at 2:09 PM: This writer called to f/u [follow up] at [hospital]. Resident passed away this morning Review of the discontinued physician orders, as of [DATE], revealed in part: .Code Status: Attempt CPR . Review of the resident's care plan, dated [DATE], revealed in part: .[Resident ID# 97's] advance directives: Attempt CPR. Full tx [treatment]: utilize full skilled nursing care . Review of the [DATE] hospital record revealed in part, .Per EMS [Emergency Medical Services] report, they were called for AMS [altered mental status] and difficulty breathing. On their arrival, patient had no pulse, no spontaneous respirations, and was unresponsive. They initiated CPR and patient remained in asystole [a condition in which the heart ceases to beat] during the duration of their transport . During a surveyor interview with Staff D on [DATE] at 2:11 PM, she revealed that she began working at 7:00 AM on [DATE], received nurse report and was on the floor rounding on her residents when she was notified by a Certified Nursing Assistant that the resident was vomiting. Upon entering the room s/he was having difficulty breathing, Staff D initiated suctioning and the resident then became unresponsive to touch. Staff D then stated that she did not assess the resident for a pulse, initiate CPR or retrieve the AED [automated external defibrillator, used to help those experiencing sudden [CONDITION(S)]] for this resident prior to the EMS services arrival to the room. During an interview with the Director of Nursing Services on [DATE] at 1:28 PM, he was unable to provide evidence that CPR was provided to the resident prior to the arrival of emergency medical personnel.

Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to protect the residents right to be free from neglect related to not providing dental services in a timely manner for 1 of 3 residents reviewed for neglect, Resident ID #84. Findings are as follows: Record review of the facility's policy for Dental Services last revised on 2/2019 states, Policy: Both routine and emergency dental services are available to meet the resident's oral health care needs based upon resident assessment and plan of care. Procedure: .4. Selected dentists must be available to provide follow-up care. Failure of a dentist to provide follow-up services will result in the facility's right to use its Consultant Dentist to provide the resident's dental needs .6. Identified individuals will will (sic) assist residents with appointments, transportation arrangements .11. All dental services provided are recorded in the resident's medical record . Record review revealed that the resident was admitted to facility in June 2019 with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 15 out of 15, indicating that the resident is cognitively intact. Record review revealed a care plan dated 6/14/2019 for .potential nutritional problem r/t (related to) chewing problems due to cracked teeth . that states in part, Coordinate arrangements for dental care, transportation as needed/as ordered .Monitor/document/report to MD (medical doctor) PRN (as needed) s/sx (signs and symptoms) of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, [MEDICAL CONDITION] . Record review revealed a physician's orders [REDACTED]. Review of a progress note dated 8/17/2019 at 10:53 PM states in part, Patient states that (his/her) tooth broke and cut (his/her) tongue. Health drive form signed by patient and faxed along with face sheet for dental exam . Review of an annual MDS dated [DATE] on Section L0200, Oral/ Dental indicated that the resident has Obvious or likely cavity or broken natural teeth. Review of a progress note dated 11/19/2019 at 2:32 PM states in part .c/o (complained of) fractured tooth, health drive notified with new enrollment signed . Record review revealed that the resident was not seen by the dental consultant until 2/18/2020. A document titled HealthDrive Dental Group dated 2/18/2020 indicated the resident received an initial dental exam. The document revealed that at the time of the exam, s/he required 3 teeth to be extracted. Additionally, the recommended treatment included a referral to an Oral Surgeon. Review of a progress note dated 3/30/2020 at 3:13 PM revealed that the resident was seen by the physician. The physician's progress note states in part, .Patient requested to be seen for tooth ache .Needed to be seen by oral surgeon to remove the tooth. I explained we could not send (him/her) to oral surgeon as COVID 19 situation .I have explained to (him/her) that we would not be able to sent (him/her) out for non critical appointments given the risk of COVID 19 .Discussed with pharmacist and DON (Director of Nursing) for OTC (over the counter) gel for tooth pain. - start [MEDICATION NAME] oral gel for tooth pain . During a surveyor interview via phone on 3/11/2021 at 12:16 PM with HealthDrive personnel, they revealed that they received the initial enrollment to see this resident on 8/17/2019. They also revealed the consulting dentist was in the facility 3 times prior to this resident initially being seen on 2/18/2020 (8/26/2019, 10/31/2019 and 1/10/2020), and the resident was not seen. This is 5 months after the initial enrolment request. Record review revealed that the resident was not seen by a dentist until 2/12/2021 with assistance by the Temporary Manager. Per the 2/12/2021 consultation, the resident needs 11 teeth extracted, instead of the previous recommendation for 3 teeth to be extracted. During a surveyor interview on 3/10/2021 at 2:15 PM with the resident, s/he indicated that it is painful to eat since his/her mouth feels sore. S/he stated that after a visit with the dentist on 2/12/2021, s/he now needs 11 teeth removed. S/he revealed that sometime in December of 2020 s/he was in so much pain that s/he pulled out of 2 of his/her own teeth. The resident then showed this surveyor the teeth s/he pulled out. During a surveyor interview with the Director of Nursing on 3/11/2021 at 2:20 PM, she could not provide evidence of other dental consults provided by Healthdrive other than the ones that occurred on 2/18/2020 and 2/12/2021. She acknowledged that there was a delay on dental treatment and this resident now requires 11 teeth to be extracted. During a surveyor interview and observation on 3/16/2021 at approximately 3:45 PM after the resident's teeth were extracted, s/he indicated s/he was in pain.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to properly prevent and contain the potential spread and transmission of COVID-19 relative to personal protective equipment (PPE) for Staff A and B. Additionally the facility failed to perform the appropriate screening and restrict staff from working for 10 staff reviewed (Staff D, E, F, G, H, I, J, K, L and M). Findings are as follows: This facility has had total of 138 COVID-19 cases since the beginning of the pandemic, 43 of these are staff and 95 are residents. Their cases have been a part of two outbreaks. The following numbers only include first-time positives, not less than 3-month positives. The first one was in April and included 10 positive staff (1 death) and 6 positive residents (0 deaths). For this outbreak the first staff positive was collected on 4/5/2020 and the first resident positive was collected on 4/17/2020. The second is the current outbreak which began on 7/3/2020, as of today 10/23/2020 they have had 33 positive staff (0 deaths) and 89 positive residents (17 deaths). 1. According to the CDC, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019, states in part, .Implement Universal Source Control Measures .( .Use of cloth face coverings or facemasks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing .) Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19 . Surveyor observations of the first-floor vestibule and foyer of the facility on 9/30/2020 at approximately 7:35 AM, revealed Staff Nurse A, entering the facility not wearing a face covering or mask. The receptionist/security allowed her to exit the vestibule via a set of locked/monitored double doors, enter the foyer and continue to the open window outside of the reception area. She was then observed ambulating to a table in the center of the foyer and looking through her personal items until the receptionist/security staff obtained a mask from the reception area and gave it to her. A subsequent observation of the first-floor vestibule and foyer of the facility at approximately 7:40 AM revealed Staff B enter the facility not wearing a face covering or mask. The receptionist/security staff then allowed her to exit the vestibule via a set of locked/monitored double doors, enter the foyer and continue to the open window outside of the reception area. The surveyor spoke briefly to Staff B to introduce herself and Staff B, continuing to remain unmasked and without a face covering, then continued to a key pad coded door and entered the office area. During an interview with the Administrator and the DNS on 9/30/2020 at approximately 10:00 AM, they could not provide evidence that all the staff were wearing proper PPE. 2. According to the CDC, Coronavirus Disease 2019 (Covid-19) .Healthcare Workers Preparing for COVID-19 in Nursing Homes .Symptoms of Coronavirus . it states in part, .Screen all HCP (Health Care Providers) at the beginning of their shift for fever and symptoms of COVID-19 .Actively take their temperature* and document absence of symptoms consistent with COVID-19 . ( .Fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting and diarrhea .) Review of the facility policy titled, Covid-19-Staff-Rhode Island, reads in part: Procedure .Staff should be screened for at risk upon arrival to work and prior to work assignment .Screening should include .Any staff identified to be at risk should be sent home . Review of facility documentation of a Covid-19 screening form from the Rhode Island Department of Health titled, Covid-19 Staff Screening Tool for Nursing Homes revealed the following statement, .If the answer to any question (symptom or quarantine) is yes, the person should be excluded from the facility . The Rhode Island Department of Health received a complaint from Registered Nurse Staff D on 10/04/2020. She indicated in her complaint that she worked while having symptoms of COVID-19 in April 2020 and was told by both the Administrator and the Regional Nurse Consultant to continue working and to stay in her office as much as possible. She stated that she filled out one screening form indicating that she was symptomatic. She also indicated that she did not continue to fill out the screening forms knowing she was symptomatic. Record review of a 4/1/2020 staff/visitor Covid-19 line list screening form for Staff D revealed a yes answer was indicated to the following two questions, .Have you experienced any respiratory symptoms (cough, sore throat, congestion) in the last 48 hours? . and .Have you experienced a fever (over 100.0) in the last 48 hours? . Review of timecard documentation for Staff D revealed that she worked every day starting April 1st though April 9th. The facility failed to provide documentation of any screening forms for her during the remaining 8 days that she worked at the facility. Review of the facility line listing documentation of Covid-19 positive staff revealed that Staff D tested positive for Covid-19 on April 9th. Review of a document titled, Grandview Risk Management Worksite Incident Report, stated in part, .diagnosed at (hospital) with Pneumonia due to Covid-19 .Describe your injury/symptoms: fever, cough, SOB (shortness of breath), difficulty breathing, muscle aches .loose stools .When? 4/9/20 . During an interview on 10/23/2020 with the Administrator he indicated that he was not in the facility during the time Staff D was symptomatic and working. Furthermore, he indicated that Staff D was responsible for reviewing the screening tools in his absence. Record review of Covid-19 staff screenings and the staff schedule for the month of September 2020 on 10/14/2020 revealed 15 screening forms related to seven different staff members. These screenings failed to provide evidence that these staff were appropriately screened and restricted from working/excluded from the facility per guidance from the CDC and the Rhode Island Department of Health. - Review of a 10/13/2020 Rhode Island Department of Health Covid-19 screening tools titled, Covid-19 Staff Screening Tool for Nursing Homes, for Staff E failed to reveal documentation of any answers selected for all the symptom and screening questions. - Review of Staff F's screening tool dated 10/13/2020 failed to reveal any answers selected for cough symptoms or screening questions regarding close/prolonged contact with someone who has tested positive for Covid-19 without wearing appropriate PPE and if Staff F has been instructed to quarantine by any public health authority. Additional review of these two screening forms and the 10/13/2020 staff schedule revealed that both Staff E and F were cleared to enter and had worked on that day. Surveyor review of the daily staff schedule followed by a subsequent interview on 10/13/2020 at approximately 3:00 PM with Staff E, revealed that she could not provide evidence that she was properly screened for symptoms and quarantining questions prior to working. - Record review of Staff G's screening tools on 9/10/2020 and 9/16/2020 indicated that she had a cough, shortness of breath/difficulty breathing, body aches, chills and runny/stuffy nose. Further record review revealed this staff was cleared to enter the building and work. During an interview with Staff G on 10/22/2020 at approximately 11:00 AM she indicated that she did answer yes to those questions and was still permitted to work. She indicated that these were chronic symptoms that she experiences. She also indicated that the facility never asked her to follow-up with her doctor regarding these chronic conditions or requested further documentation. - Record review of Staff H's screening tools on 9/7/2020, 9/9/2020, 9/17/2020, 9/21/2020, 9/22/2020 and 9/24/2020 indicated that her body aches. Further record review revealed this staff was cleared to enter the building and work on the above dates. - Record review of Staff I's screening tool on 9/29/2020 failed to reveal evidence of any answers to the quarantine screening questions such as close contacts diagnosed with [REDACTED]. - Record review of Staff J's screening tools on 9/14/2020 and 9/16/2020 failed to reveal evidence that the screening tools were completed. - Record review of Staff K's screening tool on 9/21/2020 failed to reveal evidence that the screening tool was completed. - Record review of Staff L's screening tool on 9/25/2020 revealed she was symptomatic and failed the quarantine screening. She was not prohibited from entering the facility on that date. - Record review of Staff M's screening tool on 9/14/2020 failed to reveal evidence of any answers to the quarantine screening questions and was allowed to enter the facility. During an interview with Regional Nurse Consultant, on 10/14/2020 at 12:00 PM, she was unable to provide evidence that the facility implemented an effective system of surveillance regarding staff screenings of symptoms and quarantining to prevent and control the transmission of Covid-19 in the facility. 3. Observations made by two surveyors of the facility on 10/22/2020 at approximately 12:00 PM, revealed a transmission-based precaution room on the 4th floor with two names identified on the outside door, Resident ID #3 and #4. During an interview with Staff N following these observations, it was revealed that these two residents have been quarantining together in the same room. Review of the clinical record for both residents revealed that they were readmitted to the facility from the hospital on [DATE]. Review of an admission note for Resident ID #3 revealed in part, .re-admit from (hospital) .HX (history) of . Covid pneumonia. During (his/her) hospital stayed (s/he) was treating with IV ABX (intravenous antibiotics) for Covid pneumonia .Resident is on Quarantine for 14 days due to discharge from the hospital, on Droplet Precautions . Further review of a 10/20/2020 note revealed in part, .At 5.10pm, Resident was brought into the Dinning room, post early pm care by the CNA .However, at 5.15pm, Resident was witnessed sliding off his W/C (wheelchair) onto the floor .Additional Notification(s): RN Supervisor DON . During an interview with the DNS and the Administrator on 10/22/2020 at approximately 3:00 PM, it was revealed that these residents were readmitted to the facility in separate rooms on the 3rd floor. Per the Administrator, the 3rd floor was closed because there were no Covid-19 positive resident cases in the facility. He further stated that on 10/20/2020 both residents were transferred to a shared room on the 4th floor to continue their 14 day quarantine. Neither the Administrator nor the DNS could provide an explanation as to why the facility failed to maintain Covid-19 quarantine precautions for Resident ID #'s 3 and 4.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to properly prevent and contain the potential spread and transmission of COVID-19 relative to personal protective equipment (PPE) and failure to follow isolation guidance. Findings are as follows: 1. The Center for Medicare and Medicaid Services (CMS) released a memo on 5/18/2020 for Nursing Home Reopening Recommendations for State and Local Officials which states in part, Nursing homes have been severely impacted by COVID-19, with outbreaks casing high rate of infection, morbidity, and mortality. The vulnerable nature of the nursing home population ., requires aggressive efforts to limit COVID-19 exposure and to prevent the spread of COVID-19 within nursing homes . Universal source control for everyone in the facility wear cloth face covering or facemask .All staff wear appropriate PPE when they are interacting with residents, . During a surveyor interview on 7/30/2020 at approximately 1:00 PM, the Director of Nursing Services (DNS) stated there are approximately 36 residents who tested positive for COVID-19 in the facility. Surveyor observation on 7/30/2020 between 1:00 PM and 1:45 PM and 8/4/2020 between 10:00 AM and 11:30 AM revealed the following: - Staff A was observed not wearing a face mask. He was observed entering the elevator where there was another staff member. - Staff B was observed sitting in the main dining room. She was observed wearing a face mask under her chin. Her face mask did not cover her mouth or her nose. There were 3 other staff members standing in the room (less than 6 feet apart from her). Additional surveyor observation approximately 20 minutes later, revealed Staff B sitting at the 4th floor nursing station. Her face mask was again observed on her chin and it did not cover her mouth or nose. There was another staff member sitting at the nursing station (less than 6 feet apart from her). - Staff C was observed in the main dining room wearing a face mask but the face mask did not cover her mouth or her nose. There were 2 other staff members that were in the dining room (less than unless 6 feet apart from her). During an interview with the Regional Nurse and the DNS on 7/30/2020 at approximately 2:00 PM, the DNS stated all staff are given masks upon entering the building and they are expected to wear their masks. 2. The Center for Disease Control and Prevention's guidance, titled Preparing for COVID-19 in Nursing Homes (last updated 6/25/2020), states in part: Residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of . eye protection (i.e., goggles or a face shield that covers the front and sides of the face) . Surveyor observation, in the presence of the DNS, on 08/04/2020 at approximately 11:15 AM revealed Staff D not wearing eye protection going into a COVID-19 positive resident's room (Resident ID #6) to administer medications. During an interview with Staff D, immediately following the observation, she stated she did not have eye protection wear. Staff D acknowledged that she should be wearing the eye protection going into a COVID-19 positive resident's room . When questioned about eye protection, the DNS stated all nursing staff are given eye protection, and instructed to wear it when providing care to COVID-19 positive residents. 3. The Rhode Island Department of Health (RIDOH) Coronavirus Disease 2019 (COVID-19) Quarantine and Isolation Guidance by Population updated on July 23, 2020 states in part . Symptomatic person isolate for at least 10 days until: - At least 10 days have passed since symptoms first appeared . Asymptomatic person, tested positive and does not have symptoms - Isolation may be discontinued when at least 10 days have passed since the date of their first positive diagnostic test . Work During Isolation? Yes, in limited circumstances (healthcare staff only) and in consultation with RIDOH: - If needed to fill a critical staffing position . Record review of the COVID-19 staff line list on 08/04/2020 revealed that Staff E was tested positive for COVID-19 on 07/23/2020. Review of a signed statement from Human Resources, dated 8/4/2020, revealed that Staff E returned to work on 07/30/2020, which is only 7 days since his first positive diagnosis. During a surveyor interview with the DNS on 08/04/2020 at 2:00 PM, the DNS confirmed that Staff E returned to work on 07/30/2020. 4. During surveyor observation of the second-floor unit on 8/19/2020 from approximately 11:00-11:08 AM, housekeeping staff, Staff F, was noted to be in a COVID-19 positive resident's room, wearing an N-95 Mask and gloves, the door was noted to be open. He exited the room (without washing his hands or changing his gloves) and retrieved a bottle of a cleaning agent from the housekeeping cart which was located against the opposite wall of the hallway and went back into room. He again exited the room (without washing his hands or changing his gloves) and proceeded to walk down the hall, approximately 50 feet, to the clean utility room. He entered the room by opening the door by the handle with his gloved hand. He exited the clean utility room and proceeded back down the hall and returned to the COVID-19 positive resident's room, closing the door behind him. He was observed exiting via the door of the adjoining room, of a resident that is COVID-19 negative, and returned to the housekeeping cart. During a surveyor interview with Staff F, which took place upon exiting the room and returning to his housekeeping cart, on 8/19/2020, he acknowledged the occurrences stated above, causing a breach in infection control practices. 5. During surveyor observation on 8/19/2020 at 11:21 AM of the fourth floor unit revealed nursing assistant, Staff H, remove her PPE in the doorway of Resident ID # 9's room, a COVID-19 positive room. After removing her gloves and gown, she was then observed removing her face shield and placing the contaminated face shield on top of the clean laundry cart which was just outside the room. Staff H was then observed exiting the resident's room with a full trash bag, walking through the hallway, traveling approximately 50 feet to the soiled utility room. She then exited the soiled utility room and walked back down the hallway to the shower room, which is directly across from that same resident's room, where she was then observed washing her hands. Staff H then removed her goggles, and then retrieved her contaminated face shield off the clean linen cart. She then went to nurse's station where she was observed putting her goggles and face shield in a plastic shopping bag. Staff H was not observed disinfecting the clean utility cart During a surveyor interview on 8/19/2020 at 11:26 AM with Staff H revealed she went to get a disinfectant cloth from the nurse and then wiped down the face shield and goggles after she had put the face shield on the cart. 6. During surveyor observation on 8/19/2020 at 10:10 AM of the third floor unit revealed a nursing assistant, Staff G, exiting Resident ID # 7's room with a face shield and two masks on (surgical over the KN 95). Subsequently, she was observed entering two different resident rooms and conversing with residents in their rooms, within 2-3 feet apart, without changing surgical masks between each resident. During a surveyor interview with Staff G on 8/19/2020 at 11:15 AM, she stated she was in Resident ID # 7's room for am care. She stated she removed her gown and gloves, then washed her hands in that resident's bathroom. She then disinfected her face shield with alcohol gel in that resident's bathroom. During a surveyor interview with the DNS on 8/19/2020 at approximately 12:00 PM, she stated, staff should be donning and doffing their PPE at the resident's doorway, taking off their PPE upon exiting the room and cleansing the face shield at the door before exiting. This facility has had a total of 95 cases since the beginning of the pandemic. The positive cases involved 29 staff members and 66 residents. The facility cases have been part of two outbreaks. The following numbers only include first-time positives, not greater than a 3-month span of positive cases. The first outbreak was noted in April of 2020 which included 10 positive staff members with 1 fatality and 6 positive resident cases with 0 fatalities. The facility is currently in their second outbreak, which began on 7/3/2020, and as of today, 8/21/2020, there have been 19 positive cases involving staff members with 0 fatalities and 60 positive cases involving residents with 7 fatalities. Initially, the second outbreak was contained mostly to the third floor unit involving residents, their cases have now spread to the second and fourth floor units resulting in the totals for each floor as listed below: Unknown unit = 3 residents Second floor unit = 9 residents Third floor unit = 40 residents Fourth floor unit = 8 residents

Based on surveyor observation, record review and staff interview, it has been determined the facility failed to ensure that the resident environment remains as free of accident hazards as possible, and that residdents are provided with adequate supervision to prevent elopement for 1 of 10 sampled residents at high risk for elopement (ID #1). Findings are as follows: The facility's policy titled Elopement-Missing Resident, which was last revised in January 2020, states, in part, 3. Upon return of the resident to the facility, the Director of Nursing Services or Charge Nurse should: b. Contact the Attending Physician and report what happened; c. Contact the resident's legal representative (sponsor) and inform him/her of the incident . 4. f. Charge person to track times of events should include: 1. Time of event 2. Times of notification 3. Pertinent info to search 4. Time found . i. The charge person will notify the Executive Director, Director of Clinical Services and Police regarding the missing resident after the inside search is completed or within 10 minutes. 1. Facility to provide police with a photograph of resident to assist in the search j. Person in charge should coordinate communication / notification to resident's responsible party and attending physician . 6. Upon return of the resident to the facility, the Director of Nursing Services or Charge Nurse should . c. Contact the Attending Physician and report findings and conditions of the resident. Follow orders; d. Notify the resident's legal representative (sponsor); g. Make appropriate entries into the resident's medical record . 8. Notify appropriate state agencies as required. Resident ID #1 was admitted to the facility in February 2020 with [DIAGNOSES REDACTED]. (a disorder of the nerves/nervous system caused by vitamin B1 deficiency, typically from chronic alcoholism, and marked by mental confusion, abnormal eye movements, and unsteady walk). S/he was residing on the 4th floor, which is a locked unit in the facility; keypad entry is required for elevator access and the stairwells have a keypad to exit. If the stairwell is accessed without a keypad entry the door will alarm and open in 15 seconds. Review of the Minimum Data Set (MDS) assessment for Resident ID #1 dated 6/2/2020 revealed that the resident had severe cognitive impairment and was at high risk for elopement. Review of the elopement risk assessment dated [DATE] reveals the resident received a score of 24, which indicated s/he is at a high risk for elopement. Review of the elopement care plan dated 2/20/2020 includes an intervention of distracting the resident from wandering by offering pleasant diversions. Record review of the progress notes revealed the resident attempted to elope at least 5 times since his/her admission (3/8, 3/9, 3/10, 5/26), with the last attempt on 6/1/2020 being successful. On 6/3/2020 an anonymous complainant reported the incident of elopement by Resident ID #1, which occurred on 6/1/2020. This facility is in an urban setting within a short distance of 2 heavily traveled main streets. Record review revealed Resident ID #1 first attempted to elope on 6/1/2020 at approximately 4:07 PM but was unsuccessful. Record review further revealed the last time the resident was seen on the unit was between 4:22 PM, when s/he was medicated by Staff K, and 4:30 PM, when s/he was observed by Staff L. Record review of the staff statement from the Unit Nurse, Staff M (who no longer is employed by the facility), states in part . going round the building and attempting to open the exit door near (his/her) room. Resident was redirected many times by both CNA and the writer. At around 4:20 PM, resident was medicated by the CMT. At around 5:00 PM I heard from CNA assigned to resident that she was looking for Resident ID #1 . The surveyor conducted a telephone interview with the Security Officer, Staff N, on 6/26/2020 at approximately 1:25 PM. Staff N stated that he heard the audible alarm to the double doors (near the employee break room) which leads to the outside, indicating that the door had been opened without a security code. The wall monitor in the main office where he was stationed also indicated the door was alarming. In turn, he then reviewed the video monitor, which was on the desk, to view the double doors. He stated that he did not see anyone attempting to leave the building. Next, he proceeded to check the three outside doors on the 1st floor. Eventually, he arrived at the door that had been alarming and found it to be slightly open. He acknowledged that he used the keypad to reset the door and that he did not initiate a Code Grey (the facility protocol to search for a missing resident) at that time nor did he notify supervisory staff. He further stated that approximately 5 minutes later Staff M asked if he had seen the resident. Staff N notified Staff M that he found the door to outside (staff breakroom) opened earlier and a Code Grey was initiated at that time. The surveyor interviewed the Administrator and the Director of Nursing (DON) on 6/26/2020 at 11:50 AM. The DON indicated that by the time staff responded to the 4th floor alarm door, they looked down the stairwell and did not see anyone. They then began searching the unit. After searching the unit, they realized who was missing and then staff began searching the area outside the building and across the street on foot. When the resident was not found by those on foot, the DON stated she began driving around the neighborhood looking for the resident and that she witnessed the police driving with their sirens on. She stated she followed the police which led her to the resident, who was being already evaluated by Emergency Medical Services (EMS), who were called by a bystander. The area where Resident ID #1 was located was at a busy intersection of two city streets about ¾ a mile away from the facility. The DON further stated that Resident ID #1 was bleeding from his/her mouth and had a laceration near his/her right eye area which occurred when s/he fell . The resident was subsequently transferred by ambulance to the hospital. Review of the hospital records requested by the surveyors indicated that the resident arrived at the emergency room at 6:01 PM. S/he was evaluated, a head CT scan (pictures of the brain and underneath the skull) was performed, and s/he received sutures for the eye area laceration. During surveyor interview with the resident's brother on 6/22/2020 at 11:12 AM, he revealed that the facility did not notify him or any family member that the resident had eloped, sustained an injury, or was transported to the hospital for evaluation. He stated that when he arrived to pick up Resident ID #1 for discharge the following day and asked about his/her cut near Resident ID #1's eye he was then told about the incident. During the initial entrance conference on 6/26/2020 at approximately 11:00 AM the surveyors along with the Administrator and DON toured the facility and reviewed the area of the elopement. At this time, it was discovered that the security guard can visually see that area on the video monitors but there is no sound. When someone presses on the outside door it softly beeps but not loud enough to hear the sound in the security office. Then if that person continues to egress the door for 15 seconds, that door will open and then a louder alarm will sound, and this triggers the wall monitor alarm at the security desk. The security desk from the door that the resident exited (staff breakroom) is approximately 30 feet away. It was also identified at this time that the facility was unable to provide video surveillance of this incident as it had been deleted. During a surveyor interview on 6/26/2020 at approximately 1:00 PM with the Administrator and DON they acknowledged that the facility did not notify the Department of Health of the elopement. The DON acknowledged that according to the review of the medical record, she could not provide evidence that the family or provider were notified of the elopement or emergency room visit. Neither the DON nor the Administrator could verify at what time the resident went missing, or how long the resident was missing for. The DON further acknowledged that the staff on the 4th floor did not respond appropriately to the audible stairwell alarm by thoroughly investigating the stairwell. The facility failed to ensure that the security protocol regarding responding to an alarm was followed. This resulted in a delay in locating Resident ID #1, a cognitively impaired resident, who was identified as high risk for elopement, from exiting the 4th floor locked unit stairway, travelling down 3 flights of stairs and exiting through another locked door. This delay and lack of supervision placed the resident in immediate jeopardy resulting in the resident falling and sustaining a laceration to the face requiring transfer to the hospital for sutures.

Based on record review and staff interviews, it is determined the facility failed to ensure that the resident environment remains as free of accident hazards as possible, and that residents are provided with adequate supervision to prevent elopement for 1 of 11 sampled residents at high risk for elopement (ID #247). Findings are as follows: The facility's (MONTH) 2019 policy titled Elopement, Risk Prevention And the Management of Missing Residents states, in part, under part D/ Intervention Actual Elopement: a) . Once it is determined that a resident has eloped or staff is unable to locate a resident, the following shall occur: b) A Code Grey will be announced over the intercom alerting other staff members of the emergency. i. The unit/area involved and/or ii. The room number of the missing resident iii. The time the resident is/was determined missing . c. The staff members assigned to the unit where the resident resides verify that the resident has not signed out d. Notify the center's Administrator; Director of Nursing e) Notify local law enforcement when applicable . Resident ID #247 was admitted to the facility in (MONTH) 2019 with [DIAGNOSES REDACTED]. On admission s/he was assessed as cognitively impaired with difficulty communicating and understanding others. Additionally, s/he required extensive assistance with activities of daily living (ADLs), and walking. A fall risk score of 11 and an elopement score of 10 indicated high risk. On 12/2/2019, the facility reported an incident of elopement by Resident ID #247, which occurred on 12/2/2019 at approximately 7:30 AM. The facility is in an urban setting within a short distance of 2 heavily traveled main streets. On 12/2/2019 the weather was inclement with snow and sleet. The snow continued through 12/3/2019. The surveyor interviewed the Administrator, the Director of Nursing, and the Regional Clinical Nurse Manager on 12/3/2019 at 1:30 PM. They informed the surveyor that unit staff were informed, by the Speech Language Pathologist (SLP) on 12/2/2019 at 8:00 AM, that the resident could not be located. A Code Grey was initiated. As of this interview, the resident had not been located and had been missing for approximately 30 hours. The Administrator revealed that the facility policy and protocol for elopement require any staff, becoming aware of a missing resident or hearing an alarm, notify security personnel and supervisors. This would trigger the Code Grey protocol, initiating a search for the resident. The Administrator also stated that the security staff on duty on 12/2/2019 at 7:30 AM (Staff B), heard an alarm at the reception desk indicating one of the exterior doors had been opened without the security code. Staff B inspected the keypad security monitor to determine the location of the breach and the video monitors of the exterior doors, both located in the reception/security office. He was unable to determine the location of the breach and assumed the alarm malfunctioned. He re-set the alarm and did not initiate a Code Grey, nor inform supervisory staff. Clinical record review revealed that at the time of the elopement the resident remained assessed as a high risk for falls and elopement. His cognitive ability had improved, and he was able to walk with the use of a rolling walker. However, he remained in need of skilled nursing and rehabilitation services. The facility failed to ensure that the security protocol regarding responding to an alarm was followed. This resulted in a delay in locating Resident ID #247, who eloped from the facility on 12/2/2019 during inclement weather. This delay and lack of supervision placed the resident in immediate jeopardy for serious injury or death due to her/his diagnoses, cognitive impairment, and decreased functional abilities.

Based on record review and staff interview, it was determined that the facility failed to ensure that pain management is provided consistent with professional standards of practice, relative to recognizing when the resident is experiencing pain and identifies circumstances when pain can be anticipated, for one of 5 residents, ID # 387. Findings are as follows: Record review for resident ID # 387 reveals that he was admitted to the facility 1/31/2018 post surgical amputation of left leg toes and placement of wound vac. The resident has a physicians current order dated 2/7/2018, to change the wound vac dressing every Monday, Wednesday & Friday. Review of the nurses note on 12/13/2018 at 00:12, states resident refused claim he was in pain. The surveyor interviewed the nurse, staff P, on 2/13/2018 at approximately 8:30 AM, relative to the above nurses note. Staff P stated that he wrote the note late, while working at another facility, when he realized that he had not written a note about not completing the dressing change. The surveyor questioned the nurse, staff P relative to medicating the resident in order to complete the dressing change, and he stated that he had not. Review of the pain assessments for 2/12/2018, sent to the surveyor by the Director of Nurses (DNS), revealed the following documentation of pain assessments on 12/12/2018. 2/12/2018 at 9:11 AM pain recorded at an 8 2/12/2018 at 1:27 PM pain recorded at an 8 2/12/2018 at 6:56 PM pain recorded at an 9 2/12/2018 at 9:28 PM pain recorded at an 9 The surveyor interviewed the corporate nurse on 2/13/2018 at approximately 11:30 PM, relative to the above documentation and the treatment not being completed in accordance to the physicians orders. She acknowledged that the nurse should of contacted the physician and reported that the resident was refusing his wound treatment due to pain. The corporate nurse preceded to contact the physician, and the record reveals a progress note on 2/13/2018 at 2:14 PM which states [MEDICATION NAME] HCL tablet 10 mg, by mouth every 24 hours as needed for Moderate Pain only 30 minutes prior to dressing change one table given before treatment . The facility failed to ensure that pain management was provided to resident ID # 387 who require pain medication so that the dressing could be changed in accordance with the physicians orders.

Based on surveyor observation, staff interview, and record review, it was determined that the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the plan of care for 1 of 4 residents (Resident ID#10) with non-pressure related skin ulcers. Findings are as follows: Record review for Resident ID#10 revealed [DIAGNOSES REDACTED]. Review of a podiatry consult dated 5/8/2017 revealed a podiatric [DIAGNOSES REDACTED]. The podiatrist revealed the presence of a new diabetic type ulcer on the right great toe measuring 8.0 mm by 12.0 mm by 5.0 mm (0.8 cm by 1.2 cm by .5 cm) and that the resident's pain level was 2 out of 10. Additionally, the podiatrist recommended an x-ray of the right great toe to rule out osteo[DIAGNOSES REDACTED] (infection of the bone), Doppler arterial studies to assess vascularity stat (immediately), and to have the wound care physician see the patient tomorrow. The podiatrist documented, discussed with nursing. A nursing progress note from 5/8/2017 at 6:14 PM revealed that the podiatry recommendations were verified with the physician's assistant (PA) and that the x-ray and Doppler studies were ordered. A radiology report dated 5/8/2017 revealed moderate right great toe swelling, no fracture or dislocation is seen. An ultrasound report dated 5/10/2017 revealed occlusion of superficial femoral artery. Handwritten notes initialed by the PA on the bottom of the ultrasound stated, 1. Have wound doc (doctor) see per podiatry 2. Vascular consult. Review of weekly body checks from 5/5/2017 to 6/24/2017 revealed that resident ID#10 refused except for on 5/12/2017 and 5/26/2017. On 5/12/2017 and 5/26/2017 the body checks inaccurately revealed that the resident's skin was intact with no open areas. There is no evidence of treatment to the ulcer until 6/4/2017. Review of a nursing progress note dated 6/4/2017 revealed that during care a nursing assistant (NA) noted this same open area on the resident's right great toe and reported it to the nurse. An order was obtained and implemented to wash area with normal saline, pat dry, apply [MEDICATION NAME] treatment, cover with dry clean dressing, and change daily. A podiatry consult dated 6/5/2017 revealed that resident ID#10 was seen for follow up for a non-healing toe wound. The podiatrist revealed the ulcer on the right great toe increased in size and pain. It measured 15.0 mm by 30.0 mm by 5.0 mm (1.5 cm by 3.0 cm by 0.5 cm) and that the resident's pain level was 4 out of 10. The podiatrist recommended a vascular physician consult and wound care physician to see tomorrow. The resident was seen by the wound physician on 6/6/2017 as indicated in a nursing progress note. Review of a physician's telephone order dated 6/6/2017 revealed an order to discontinue the previous right great toe treatment. An order was obtained and implemented to wash great toe with normal saline use Iodosorb (wound gel) and cover with dry dressing daily, and obtain a vascular consult. A Care Plan developed on 6/15/2017 revealed that the resident has a venous/stasis ulcer of the right great toe. The goal is for the resident to have no signs and symptoms of infection and the resident's ulcer will be healed by the review date (9/14/2017). Interventions include: evaluate wound, elevate legs as much as possible, vascular consult, and weekly treatment documentation. A continuity of care form dated 6/22/2017 from the vascular surgeon revealed recommendations to see a wound physician and return for a follow up appointment on 7/24/2017. Review of the record revealed that resident ID #10 has been seeing the wound care specialist since 6/6/2017. The last wound progress note from 7/12/2017 revealed wound progress as improved and that there is no indication of pain associated with this condition. Observation of wound care on 7/18/2017 at 2:15 PM revealed a dressing intact on right great toe dated 7/16/2017 and wound care was provided as currently ordered by the physician. During a surveyor interview with the Director of Nursing Service on 7/19/2017 at 8:15 AM she was unable to provide evidence that the right great toe wound had been addressed or treated during the time on 5/10/2017 to 6/4/2017 resulting in it increasing and size and pain to the resident. She could provide documentation that the facility is now in compliance with providing care to the resident's wound.

Based on record review and staff interviews the facility failed to provide basic life support, including CPR (cardio-pulmonary resuscitation), per physician orders, resident's advance directives, and facility policy to a resident found unresponsive for 1 of 1 resident (Resident ID #4) in which advance directives were not followed. Findings are as follows: Closed record review for resident ID #4 revealed [DIAGNOSES REDACTED]. The resident was admitted to the facility initially on [DATE]. The resident was hospitalized from [DATE] to [DATE] with a [DIAGNOSES REDACTED]. Review of the resident's Advance Directive Declaration signed by the resident and physician on [DATE] indicates that s/he was a FULL CODE: Refers to the use of all therapeutic measures to sustain life include hospitalization if necessary. Physician's monthly orders reviewed for [DATE] to [DATE] revealed under advanced directives that the resident was a full code, the orders were signed by the physician. A review of the discharge summary note from [DATE] at 3:16 PM revealed that the resident was out of bed sitting in his/her wheelchair by the nurse's station until about 2:00 PM and had eaten half of lunch. The resident's assigned NA (nursing assistant) reported that the resident was not looking good. The nursing assessment revealed that the resident's skin was pale and had s/he had abnormal breathing. The nurse revealed the resident was made comfortable, care was provided, and the resident took their last breath shortly after care. Additionally, the nurse noted that pupils were dilated, apical and carotid pulses and breath sounds were absent. The resident was pronounced dead at 2:40 PM and the POA (power of attorney) and PA (physician's assistant) were notified. Further review of resident ID #4's progress notes revealed a [DATE] 5:15 AM nursing note indicating that the resident was experiencing a medical decline and the nurse called the POA to confirm code status was a full code. During surveyor interview with the Director of Nursing (DON) in the presence of the Administrator on [DATE] at 8:35 AM she revealed that CPR was never initiated and confirmed that the resident was a full code. The surveyor interviewed Staff Nurse A in the presence of the DON and two additional surveyors on [DATE] at 11:47 AM. She revealed that on [DATE] she went to the resident's record, found the advance directive was blank and called medical records for the to locate a completed advance directive. The staff nurse revealed that she was aware that CPR should have been initiated in the absence of an advance directive. Review of the facility policy: Emergency Procedure Code Blue Cardiopulmonary Resuscitation, date initiated ,[DATE], provided on [DATE] at 10:00 AM by the DON, indicated the following, in part: .4. The team leader shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual Review of document titled, Quality Assurance and Performance Improvement Ad Hoc Committee Meeting dated [DATE] revealed minutes that addressed resident's code status was not followed. Interventions included: full house audit of code status was completed, advance directives roster was created and distributed to all disciplines, advance directives care plans will be initiated or updated beginning on [DATE] and ongoing until completed, in servicing for nursing staff on advance directives policy and proper procedures to follow when a resident is a full code versus DNR, in servicing for Director of Social Work about maintaining an accurate advance directives roster and regularly distributing the roster to all departments, and that the plan of correction will be completed by the acting DON. Through record review of 15 active and closed records, completed advance directives were located by surveyors. Additionally, nursing staff could identify where to locate the resident's code status and describe what to do in the absence of a copy of the advance directive. The facility failed to provide cardiopulmonary resuscitation in accordance with the resident's wishes and physician's orders. The resident subsequently died .