Every finding on record at AdviniaCare Scallop Shell, LLC

Based on record review and staff interview, the facility failed to ensure adequate supervision and timely intervention for Resident ID #9, a resident with documented dysphagia (swallowing difficulties), to prevent accident hazards related to choking. Despite multiple documented episodes of the resident coughing and choking during meal and medication consumption between October 23, 2025, and October 27, 2025, the facility staff failed to implement any immediate, necessary interventions or notify the medical provider of the significant change in condition as required by policy and the resident's care plan. This failure resulted in a severe choking event on October 28, 2025, where the resident was found to be cyanotic (blue in the face) and required staff intervention to manually remove food, placing the resident in Immediate Jeopardy of serious injury, aspiration pneumonia, or death.Findings are as follows:Review of a policy titled Physician Notification of Emergency or Change of Condition, last modified on 5/30/2019, states in part, On an ongoing basis, the Resident Care Manager, Licensed Nurse or Shift Supervisor will evaluate the Resident's status and respond to any changes in the Resident's condition to ensure immediate access to the appropriate necessary services. The Resident Care Manager/designee will notify the Primary Physician and all disciplines, as appropriate of the Resident's emergency or change of condition. The Resident's Physician will provide instructions to the care staff when emergency treatment is determined to be necessary for a resident due to illness, injury or change of condition or behavior. The resident's safety and comfort will be protected at all times.a change of condition is defined as a change in the Resident's mental, physical, emotional or medical status.Record review revealed Resident ID #9 was admitted to the facility in April of 2025 with diagnoses including, but not limited to, Parkinson's Disease and dysphagia (difficulty swallowing).Record review revealed a physician's order dated 9/19/2025 for a no added salt (NAS) diet with regular texture and regular liquid consistency, with whole sandwiches allowed.Record review of a care plan last revised on 7/17/2025 revealed, the resident has mild oral pharyngeal dysphagia (a condition characterized by difficulty swallowing, primarily affecting the mouth and throat) and cannot drink through a straw with a goal which states I will exhibit no signs of aspiration [inhaling an object or fluid into the airways which can lead to coughing, difficulty breathing, discomfort, and/or choking] or difficulty swallowing before my next review date. Further review of the care plan revealed to report any changes to the medical provider.Record review revealed the following progress notes:- 10/23/2025: the resident was coughing during meals- 10/24/2025: the resident has been having coughing episodes during meals and speech therapy was notified- 10/26/2025: the resident had an episode of choking on his/her food during dinner- 10/27/2025: the resident had an episode of choking during the medication pass but was able to swallow pills eventually- 10/28/2025: the resident was found to have a blue face, actively choking, requiring the use of back slaps. The food was removed from the mouth with a finger sweep, the provider was notified, and new orders were obtained which included, to obtain a chest x-ray to evaluate for possible aspiration, obtain vital signs for 24 hours, and the resident's diet was downgraded to a pureed diet (soft pudding like consistency). S/he complained of shortness of breath with crackles noted at bilateral (affecting both sides) lung bases. Record review failed to reveal evidence the provider was notified of the resident's increased coughing and choking with meals and/or medications on 10/23, 10/24, 10/26 and 10/27/2025. Further review failed to reveal evidence that an intervention was implemented in the resident's care plan to prevent the choking incident that occurred on 10/28/2025.Review of a document titled Referral to Therapy, dated 10/26/2025, revealed a list of symptoms that would warrant a therapy referral. Under the section labeled Signs of Aspiration, the symptoms Choking and Frequent Coughing were marked on 10/26/2025 as reasons for the referral. Further review revealed that speech therapy evaluated the resident on 10/28/2025.During surveyor interviews on 11/18/2025 at 12:08 PM and 12:30 PM, with Unit Manager, Staff D, she revealed that the resident often has episodes of choking while eating but is able to clear the contents him/herself. When questioned again by the surveyor if it was coughing or choking, Staff D responded choking. She acknowledged the resident had coughing and/or choking documented in his/her progress notes on 10/23, 10/24, 10/26 and 10/27/2025. She revealed that she was unable to find evidence that the provider was notified of the coughing on 10/23 and 10/24/2025 or the choking on 10/26 and 10/27/2025. Additionally, she was unable to provide evidence that an intervention was implemented following the coughing and choking episodes on 10/23, 10/24,10/26 and 10/27/2025 to prevent the choking episode on 10/28/2025.During a surveyor interview on 11/18/2025 at 1:02 PM, NP, Staff E, she stated that she works with NP, Staff C. She revealed that she was present after the choking incident on 10/28/2025 and accompanied the speech therapist to assess the resident. The speech therapist screened the resident and subsequently changed the resident's diet to pureed. Staff E revealed that she would expect staff to notify a provider if a resident exhibited increased coughing or choking episodes and that she would expect interventions to be implemented to prevent choking.During a surveyor interview on 11/18/2025 at 1:08 PM with the Administrator and the Interim Director of Nursing Services (DNS), they revealed that they would expect staff to notify the provider if the resident was having increased coughing/choking. Additionally, they revealed they would expect the staff to implement interventions to keep the resident's safe.During a surveyor interview on 11/19/2025 at 8:11 AM, Registered Nurse, Staff F, he acknowledged that he documented in the resident's progress notes that the resident was observed choking on 10/26 and 10/27/2025. He stated that on 10/26/2025 he heard the resident coughing, went to assess the situation and observed the resident having difficulty swallowing food, accompanied by coughing and dry heaving. Staff F also imitated the sound of someone gasping for air due to a throat obstruction to describe the resident's presentation and stated that the resident was unable to speak during the episode. He further revealed, on 10/27/2025 the resident presented in the same manner while attempting to swallow medication. When asked whether he notified the provider about the resident's difficulty swallowing, coughing, or choking, Staff F responded, no. When asked if he removed the resident's meal tray and replaced it with a softer, easier-to-swallow option on 10/26/2025, he again responded, no, I didn't think of that. Lastly, when questioned whether he moved the resident to a supervised location to finish meals or for subsequent meals, he responded, no.During a surveyor interview on 11/19/2025 at 7:53 AM with the Administrator, the Interim DNS, and the Speech Therapist, that were unable to provide evidence an intervention was implemented on 10/23, 10/24, 10/26, and 10/27/2025 for the coughing/choking episodes. The Speech Therapist revealed that he received the referral to therapy on Monday 10/27/2025 but did not screen the resident on that Monday because the screen did not indicate the resident was choking, as the handwritten note read coughing during meals, although choking was marked off as a concern on the form. Lastly, they revealed that they were unable to provide evidence that a provider was notified on 10/23, 10/24, 10/26, and 10/27/2025, per the policy and care plan.As a result of this failure on 10/23, 10/24, 10/26, and 10/27/2025, the resident was found on 10/28/2025 blue in color, actively choking, requiring the staff to provide a back slap and a finger sweep, to remove food from the resident's mouth. This failure had the potential to cause more than serious harm, serious impairment, serious injury, or death.Refer to F 726

Based on surveyor observation, record review, and staff interview, the facility failed to ensure that appropriate treatment and services were provided to one resident (Resident ID #70) who was reviewed for fluid management. This failure included missing two physician-ordered doses of Lasix (a medication used to treat excess fluid trapped in the body's tissue) and failing to obtain daily weights as ordered by the physician. As a direct result of these failures, the resident experienced clinical deterioration, including increased shortness of breath and an elevated respiratory rate (30 breaths per minute), requiring an immediate transfer to the hospital for evaluation of potential congestive heart failure exacerbation.Findings are as follows:Review of a policy titled Electronic Physicians Orders (Create, Confirm, Processing orders) last modified 8/28/2024, states in part, .Routine orders- Electronic prescriptions/orders will be obtained in the following manner: Verbally.written in the paper chart or entered into the EMR [Electronic Medical Record] by the medical provider.The Licensed Nurse.who has obtained the order from the MD/PA/NP [Medical Doctor/Physician Assistant/Nurse Practitioner] transcribing the medical order in to the EMR will ensure the correct date, time, ordering prescriber, medication name, order category, communication method, route of administration, frequent, schedule, indication for use or diagnosis.are listed.Record review revealed Resident ID #70 was admitted to the facility in October of 2025 with diagnoses including, but not limited to, acute on chronic diastolic congestive heart failure (a condition where the heart is unable to pump blood effectively, leading to fluid buildup in the lungs causing difficulty breathing and other parts of the body such as the arms and legs) and chronic obstructive pulmonary disease (a lung condition caused by damage to the lungs).During a surveyor observation on 11/18/2025 at 10:01 AM, the resident was noted to have edema to his/her upper and lower extremities.1. Record review revealed a care plan, last revised 11/17/2025, states in part, I have an alteration in respiratory status. with interventions that include, but not limited to, administer medications per MD/NP order.Review of a handwritten physician order revealed an order dated 11/14/2025 for Lasix 20 milligrams (mg), every afternoon for 4 days.Further review revealed an additional order dated 11/17/2025 for Lasix 20 mg, every evening on 11/18/2025 and 11/19/2025.Record review revealed a progress note authored by NP, Staff C, on 11/17/2025 which states in part, .Patient noted with 4 pounds weight gain yesterday. Overall edema to lower extremities has improved. Patient has been receiving an extra 20 mg of Lasix on Friday [11/14/2025], Saturday [11/15/2025], Sunday [11/16/2025], and Monday [11/17/2025]. Will extend extra 20 mg of Lasix for Tuesday [11/18/2025] and Wednesday [11/19/2025]. Left arm edema is improved. This indicates the resident was to receive a total of 6 days of additional Lasix.Record review revealed the resident weight on the following dates:-10/26/2025: 155.2 pounds (lbs)-11/9/2025: 164.4 lbs-11/11/2025: 166 lbs-11/16/2025: 168.4 lbs-11/18/2025: 171.0 lbsRecord review of the November 2025 Medication Administration Record revealed that the resident received only 4 additional days of Lasix on 11/15/2025, 11/16/2025, 11/17/2025, and 11/18/2025 and not the 6 days of as Lasix ordered. The 11/14/2025 and 11/19/2025 doses were not signed off as administered.During a surveyor interview on 11/20/2025 at 11:25 AM, with Unit Manager, Staff D, she acknowledged that the resident did not receive the 6 days of Lasix as ordered and did not receive a dose last night, 11/19/2025. Additionally, she revealed that the resident is currently having a hard time breathing and his/her respiratory rate is elevated requiring immediate interventions.During surveyor interviews on 11/20/2025 at 11:41 AM and 12:37 PM, with NP, Staff C, she revealed that she would have expected the Lasix order to have been administered for a total of 6 days. Additionally, she revealed that the resident was noted to have pursed lip breathing (a type or breathing observed when someone has difficulty breathing), the resident's respiratory rate was 30 breaths per minute (normal respirations is 12 to 20), and that the resident will be transferred to the hospital.1b. Record review revealed a care plan, last revised 11/17/2025, states in part, I have a potential for alteration in nutrition.11/17/25-weight trending up.daily weights. with interventions to include, but not limited to, Monitor and record weights and Update MD/NP/PA on resident status, as needed. Record review revealed a progress note dated 11/16/2025 which revealed, the resident has had an increased weight gain over the past 3 weeks, with a total weight of 13.2 pounds in the 3 weeks since admission. Additionally, the resident had a 2.4-pound weight gain in 4 days and has shortness of breath on exertion and is utilizing oxygen at 3 liters. The on-call provider was notified, and an order was obtained for daily weights.Record review revealed a physician's order dated 11/17/2025 for daily weights.Review of the Medication Administration Record and weight log for November of 2025, failed to reveal evidence that a weight was obtained on 11/17/2025 and 11/19/2025During surveyor interviews on 11/20/2025 at 11:41 AM and 12:37 PM, with NP, Staff C, she revealed that she would have expected the daily weights to have been obtained, or a reason documented as to why they were not.During a surveyor interview on 11/20/2025 at 11:45 AM, with the Interim Director of Nursing Services, she acknowledged that the resident only received an additional 4 doses of Lasix and not the 6 doses, as ordered. Additionally, she acknowledged that the resident was not weighted daily per the physician's order and would have expected the daily weights to have been obtained, as ordered. Further, she acknowledged that the resident was currently having increased shortness of breath and was being sent to the hospital for evaluation. Review of the hospital Discharge summary dated [DATE], revealed that although the patient was favored to have chronic obstructive pulmonary disease exacerbation, a congestive heart failure exacerbation cannot be ruled out.

Based on record review and staff interview, the facility failed to ensure that Registered Nurse, Staff F, was competent to provide nursing services related to acute changes in condition, which resulted in actual harm to Resident ID #9. Despite having been competency-trained and observing the resident choking on food and medication on 10/26 and 10/27/2025, Registered RN, Staff F failed to follow policy and the resident's care plan by neglecting to immediately implement an intervention (such as removing the meal or providing a softer diet option) and failing to notify the resident's provider. This immediate failure to act and notify on a serious change in condition led to the resident experiencing a severe, life-threatening choking episode on 10/28/2025, requiring emergency physical intervention and resulting in signs of aspiration pneumonia, which mandated a diet change and further medical workup.Findings are as follows:Review of a policy titled, Physician Notification of Emergency or Change of Condition, last modified on 5/30/2019, states in part, On an ongoing basis, the Resident Care Manager, Licensed Nurse or Shift Supervisor will evaluate the Resident's status and respond to any changes in the Resident's condition to ensure immediate access to the appropriate necessary services. The Resident Care Manager/designee will notify the Primary Physician and all disciplines, as appropriate of the Resident's emergency or change of condition. The Resident's Physician will provide instructions to the care staff when emergency treatment is determined to be necessary for a resident due to illness, injury or change of condition or behavior. The resident's safety and comfort will be protected at all times.a change of condition is defined as a change in the Resident's mental, physical, emotional or medical status.Record review revealed Rn, Staff F was hired on 4/24/2025. Further review revealed he completed a competency titled, Observing and Reporting Changes in Condition on 5/6/2025. Record review revealed Resident ID #9 was admitted to the facility in April of 2025 with diagnoses including, but not limited to, Parkinson Disease and dysphagia (difficulty swallowing).Record review of a care plan last revised on 7/17/2025, revealed, the resident has mild oral pharyngeal dysphagia (a condition characterized by difficulty swallowing, primarily affecting the mouth and throat) with a goal which states I will exhibit no signs of aspiration [inhaling an object or fluid into the airways which can lead to coughing, difficulty breathing, discomfort, and/or choking] or difficulty swallowing before my next review date. Further review of the care plan revealed to report any changes to the medical provider.Review of the progress notes revealed the following authored by Staff F:- 10/26/2025: the resident had an episode of choking on his/her food during dinner- 10/27/2025: the resident had an episode of choking during the medication pass but was able to swallow pills eventuallyAdditional review of the progress notes revealed a note dated 10/28/2025, which revealed the resident was found to have a blue face, actively choking, requiring the use of back slaps. The food was removed from the mouth with a finger sweep, the provider was notified, and new orders were obtained which included, to obtain a chest x-ray to evaluate for possible aspiration, obtain vital signs for 24 hours, and the resident's diet was downgraded to a pureed diet (soft pudding like consistency). S/he complained of shortness of breath with crackles noted at bilateral (affecting both sides) lung bases. Record review failed to reveal evidence Staff F notified the resident's provider of his/her episodes of choking with meals and/or medications on 10/26 and 10/27/2025. Further review failed to reveal evidence that an intervention was implemented by Staff F in the resident's care to prevent the choking incident on 10/28/2025.During a surveyor interview on 11/18/2025 at 1:02 PM, Nurse Practitioner (NP), Staff E, she stated that she works with NP, Staff C. She revealed that she was present after the choking incident on 10/28/2025 and accompanied the speech therapist to assess the resident. The speech therapist screened the resident and subsequently changed the resident's diet to pureed. Staff E revealed that she would expect staff to notify a provider if a resident exhibited increased coughing or choking episodes and that she would expect interventions to be implemented to prevent choking.During a surveyor interview on 11/19/2025 at 8:11 AM, Registered Nurse, Staff F, he acknowledged that he documented in the resident's progress notes that the resident was observed choking on 10/26 and 10/27/2025. He stated that on 10/26/2025 he heard the resident coughing, went to assess the situation and observed the resident having difficulty swallowing food, accompanied by coughing and dry heaving. Staff F also imitated the sound of someone gasping for air due to a throat obstruction to describe the resident's presentation and stated that the resident was unable to speak during the episode. He further revealed, on 10/27/2025 the resident presented in the same manner while attempting to swallow medication. When asked whether he notified the provider about the resident's difficulty swallowing, coughing, or choking, Staff F responded, no. When asked if he removed the resident's meal tray and replaced it with a softer, easier-to-swallow option on 10/26/2025, he again responded, no, I didn't think of that. Lastly, when questioned whether he moved the resident to a supervised location to finish meals or for subsequent meals, he responded, no.During a surveyor interview with the Administrator, the Interim Director of Nursing Services, and the Speech Therapist, on 11/19/2025 at 7:53 AM, they were unable to provide evidence of an intervention implemented by Staff F on 10/26 and 10/27/2025, or that a provider was notified by Staff F, of the resident's choking incidents, as per the policy and care plan.Refer to F 689

Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident's drug regimen is free from unnecessary medications for 2 of 2 residents reviewed for blood pressure medications with parameters, Resident ID #s 4 and 83 and for 1 of 1 resident reviewed for pain, Resident ID #79. Findings are as follows:1a. Review of a policy titled, Medication Administration Methods, dated 1/25/2024, states in part, .The nurse will take the pulse or blood pressure when a medication requires such. He/She will then record the results on the Medication Administration Record/ EMAR prior to medication administration.Record review revealed Resident ID #4 was readmitted to the facility in October of 2025 with diagnoses including, but not limited to, hypotension (low blood pressure) and heart failure.Record review revealed a physician's order dated 10/27/2025 for Metoprolol Succinate (a blood pressure medication) tablet extended release 25 milligrams (mg), to administer 1 tablet by mouth in the morning and hold if the heart rate is less than 60 beats per minute or if the systolic blood pressure (SBP, the top number in a blood pressure reading that refers to the amount of pressure experienced by the arteries while the heart is beating) is less than 100.Record review of the November 2025 Medication Administration Record (MAR) revealed, 13 out of 19 days the Metoprolol was administered without a heart rate reading being documented.Further record review revealed a physician's order dated 11/1/2025 for Losartan Potassium (a blood pressure medication) oral tablet 25 mg, give 1 tablet by mouth and hold for a SBP of less than 110.Review of the November 2025 MAR revealed the Losartan was administered on the following dates with a SBP of less than 110:- 11/1, 100/63- 11/4, 106/62- 11/5, 101/63- 11/7, 107/63- 11/9, 105/62- 11/10, 106/60- 11/11, 103/65- 11/15, 108/62- 11/16, 109/72During a surveyor interview on 11/20/2025 at 10:43 AM with Unit Manager (UM), Staff D, she acknowledged that the heart rate for administration of the Metoprolol was not documented. Additionally, she acknowledged that the Losartan was administered outside of the ordered parameters.During a surveyor interview on 11/20/2025 at 10:50 AM with the Interim Director of Nursing Services (DNS), she revealed that she would expect the staff to follow the physician's order including following the parameters to hold the medication.1b. Record review revealed Resident ID #83 was admitted to the facility in November of 2025 with diagnoses including, but not limited to, heart failure and dementia.Record review revealed a physician's order dated 11/11/2025 for Metoprolol Succinate extended release 100 mg, give 1 tablet by mouth and hold for a SBP less than 110 or a heart rate of less than 60 beats per minute.Review of the November 2025 MAR revealed that the Metoprolol was administered on 11/13/2025 with a blood pressure of 103/64.During a surveyor interview on 11/20/2025 at 11:50 AM, with the Interim DNS, she revealed that she would expect the staff to follow the physician's order including following the parameters to hold the medication.2. Record review revealed Resident ID #79 was admitted to the facility in November of 2025 with a diagnosis including, but not limited to, chronic pain.Record review revealed a physician's order dated 11/11/2025 for Hydrocodone-Acetaminophen (a medication prescribed to trat pain) 10-325 mg, administer 1 tablet by mouth every 6 hours as needed for pain.Additional record review revealed a physician's order dated 11/12/2025 for Acetaminophen oral tablet 500 mg, administer 2 tablets every 8 hours as needed for pain. Further review of the order revealed special instructions to ensure that the Acetaminophen dosage with both the as needed Hydrocodone-Acetaminophen and the as needed Acetaminophen dose, does not exceed the max dosage of 3000 mg in 24 hours.Review of the November 2025 MAR revealed that on 11/16/2025 Resident ID #79 received 4 doses of as needed Hydrocodone-Acetaminophen 10-325 mg and 2 doses of as needed Acetaminophen 1000 mg to total 3300 mg of Acetaminophen in 24 hours.During a surveyor interview on 11/19/2025 at 1:10 PM with UM, Staff D, she acknowledged that on 11/16/2025 the resident received more than the maximum dosage of Acetaminophen.During a surveyor interview on 11/19/2025 at 1:16 PM with the Interim DNS, she revealed that she would have expected the staff to follow the physician's orders. Additionally, she was unable to provide evidence that Resident ID #s 4, 79, and 83 were kept free from unnecessary medications.

Based on record review and staff interview, it has been determined that the facility failed to properly provide notice to residents and/or representatives informing them of when changes in coverage are made to items and services covered by Medicare and/or the state Medicaid plan, relative to the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) of Non-coverage Form for 3 of 3 residents discharged from Medicare Part A Services that remained in the facility, Resident ID #s 17, 22, and 30.Findings are as follows:Review of the Center for Medicare and Medicaid Services (CMS) Form, CMS 100-55, titled Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage, states in part:Medicare requires SNFs [Skilled Nursing Facilities] to issue the SNFABN to Original Medicare, also called fee-for-service (FFS) beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is:- not medically reasonable and necessary.- or considered custodial.The SNFABN provides information to the beneficiary so that s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. SNFs must use the SNFABN when applicable for SNF Prospective Payment System services (Medicare Part A) .Review of a policy titled, Room and Care Medicare Part A Billing, last revised 5/23/2022, states in part, .Issuance of SNF Advanced Beneficiary Notice Form (SNF ABN).Completion of this notice provides estimated costs of SNF services to be received but will not be covered by Traditional Medicare after the last day of Medicare A coverage. (This must be completed prior to change of liability upon competition of Traditional Part A benefits).NOTE.The SNF ABN 1005 must be delivered prior to the change of financial liability but does not hold the same two (2) day requirement. Best practice is to issue both notices simultaneously.A) Record review revealed Resident ID #17's last covered day of Medicare Part A Services was on 5/30/2025. Further record review failed to reveal evidence that the resident and/or resident representative was issued the SNFABN form.B) Record review revealed Resident ID #22's last covered day of Medicare Part A Services was on 10/24/2025. Further record review failed to reveal evidence that the resident and/or resident representative was issued the SNFABN form.C) Record review revealed Resident ID #30's last covered day of Medicare Part A Services was on 10/22/2025. Further record review failed to reveal evidence that the resident and/or resident representative was issued the SNFABN form.During a surveyor interview on 11/19/2025 at 10:52 AM with Minimum Data Set (MDS) Nurses, Staff A and MDS Nurse, Staff B, they acknowledged that Resident ID #s 17, 22, and 30, nor their representatives, were not issued a SNFABN form and acknowledged that they should have been.During a surveyor interview on 11/19/2025 at 11:04 AM, with the Administrator and the Interim Director of Nursing Services, they were unable to provide evidence that the facility provided the SNFABN notice for Resident ID #s 17, 22, and 30, as required.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to meet professional standards of quality related to not following physician's orders for 1 of 2 residents reviewed for wound care, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health, dated 9/12/2024 alleges the resident's wound dressings on his/her leg, hip and lower back are not being changed as ordered. 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 the resident was admitted to the facility in August of 2024 with diagnoses including, but not limited to, pressure ulcer of left hip, pressure ulcer of sacral region and osteomyelitis (bone infection). Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating an intact cognition. Record review revealed the following physician's orders: - 8/22/2024 - Wound care to the left hip pressure wound. Cleanse wound with normal saline, pat dry and apply Medihoney (a medical-grade wound care dressing made from honey), and cover with an Allevyn (a type of wound dressing) foam dressing daily. - 8/22/2024 - Wound care to the sacrum. Cleanse wound with normal saline, pat dry and apply Medihoney (and cover with an Allevyn foam dressing daily. - 8/23/2024- Wound care to left buttock. Cleanse with normal saline and pat dry, apply Biostep (a collagen dressing) and cover with a bordered foam dressing and change daily. Record review of the Treatment Administration Record (TAR) for September of 2024 failed to reveal evidence that the resident's daily wound dressings were completed on the following dates: - Left hip pressure wound- 9/9/2024, 9/11/2024 and 9/12/2024 - Pressure wound on the sacrum- 9/9/2024, 9/11/2024 and 9/12/2024 - Left buttock wound- 9/9/2024, 9/11/2024 and 9/12/2024 During a surveyor interview on 9/13/2024 at 12:44 PM with the resident, s/he revealed that his/her dressings are supposed to be changed daily however s/he stated that they are not. During a surveyor interview on 9/13/2024 at approximately 1:00 PM with Licensed Practical Nurse, Staff A, she indicated that the resident does not have daily dressing changes. Additionally, after checking the medical record, she acknowledged that the resident does have physician's orders for daily dressing changes after it was brought to her attention by the surveyor. During a surveyor observation on 9/13/2024 at 1:32 PM of the resident's dressing changes in presence of Staff A, the dressings on the pressure wound on the sacrum, the left hip pressure wound and the left buttock were all dated 9/11/2024, indicating that they were not changed daily as ordered. Further observation revealed that the dressings on the sacrum and the left hip were observed to be visibly soiled with wound drainage. During a surveyor interview following the observation, Staff A acknowledged that the dressings were dated 9/11/2024. Additionally, she was unable to explain why they were not completed on 9/12/2024, as ordered. During a surveyor interview on 9/13/2024 at 2:26 PM with the Director of Nursing Services in presence of the Administrator, she was unable to explain why the resident's dressings were not completed on 9/12/2024 as ordered. Additionally, she was unable to provide evidence of documentation in the resident's record that s/he had refused any dressing changes on 9/11/2024.

Based on record review and staff interview, it has been determined that the facility failed to ensure that hospice services meet professional standards of principles that apply to individuals providing services in the facility for 2 of 2 residents reviewed who are receiving hospice services, Resident ID #s 23 and 28. Findings are as follows: 1) Record review revealed that Resident ID #23 was admitted to the facility in December of 2023 with a diagnosis including, but not limited to, Alzheimer's disease. Record review revealed the resident started with hospice services in 12/2023. Review of the electronic and paper medical records failed to reveal evidence of the following hospice information, per regulation: - The most recent hospice plan of care - Hospice election form - Physician certification and recertification of the terminal illness - Names and contact information for hospice personnel involved in hospice care - Instructions on how to access the hospice's 24-hour on-call system - Hospice medication information - Hospice physician and attending physician orders 2) Record review revealed that Resident ID #28 was admitted to the facility in April of 2022 with a diagnosis including, but not limited to, diverticulosis of the intestine (a condition of having small pouches or pockets in the inside walls of your intestines). Record review revealed the resident started with hospice services in 4/2024. Review of the electronic and paper medical records failed to reveal evidence of the following hospice information, per regulation: - The most recent hospice plan of care - Hospice election form - Physician certification and recertification of the terminal illness - Names and contact information for hospice personnel involved in hospice care - Instructions on how to access the hospice's 24-hour on-call system - Hospice medication information - Hospice physician and attending physician orders During a surveyor interview on 9/5/2024 at 11:13 AM, with the Administrator, she revealed that the facility does not have individual hospice binders for each resident receiving hospice services and indicated that all hospice documents should be scanned into the electronic medical records. During surveyor interviews on 9/5/2024 at 11:31 AM and 12:40 PM, with the Director of Nursing Services (DNS), she acknowledged that the facility does not have individual hospice binders for each resident receiving hospice services. She revealed that all hospice information, including the hospice plan of care, should be in the hospice section of each resident's chart. The DNS was unable to provide evidence of the above-mentioned hospice documents for Resident ID #s 23 and 28. During a surveyor interview on 9/6/2024 at 1:06 PM, with the Administrator and DNS, they revealed that all the hospice documents mentioned above were obtained from the hospice providers and were now put into the resident's chart, after the concern was brought to the facility's attention by the surveyor. 46715

46715 Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive care plan relative to 1 of 1 resident reviewed with a skin graft, Resident ID #24 and 2 of 4 residents reviewed with known skin impairments who lacked weekly skin assessments, Resident ID #s 9 and 257. Findings are as follows: 1. Record review revealed Resident ID #24 was admitted to the facility in June of 2023 with diagnoses including, but not limited to, heart failure and malignant neoplasm of the skin (skin cancer). Review of a Dermatology Professionals Visit Note dated 8/23/2024 revealed that Resident ID #24 has a new skin graft (a type of surgery where providers take healthy skin from one part of the body and move it. The healthy skin covers or replaces skin that is damaged or missing) to his/her left upper arm. Additionally, it revealed that the skin graft requires daily dressing changes. Record review failed to reveal evidence at the time of the skin graft on 8/23/2024 that the skin ulcer/wound (skin graft) was documented in the medical record to include the underlying condition contributing to the wound, wound edges, and the wound bed, location, shape and the condition of surrounding tissue per the regulation. During a surveyor interview on 9/5/2024 at 12:17 PM with the Director of Nursing Services (DNS), she acknowledged that there was no documentation regarding Resident ID #24's skin graft on 8/23/2024. Additionally, she revealed that she would expect weekly documentation including the type of wound, measurements, the type of tissue, symptoms of infection, presence of drainage, wound edges, and pain. 2. Review of a facility policy titled, Skin Care Program dated 5/8/2018 states in part, .Licensed Staff will complete a weekly skin examination and document in the medical record . a. Record review revealed that Resident ID #9 was admitted to the facility in November of 2019 with diagnoses including, but not limited to, type II diabetes mellitus and peripheral vascular disease (a condition in which narrowed arteries reduce blood flow to the arms or legs). Review of a care plan dated 11/8/2023 revealed the resident is at risk for skin impairment with an intervention including, but not limited to, conduct systemic skin inspections weekly and as needed and to document findings. Record review of a skin assessment dated [DATE] revealed Resident ID #9 did not have any skin impairments. Record review failed to reveal evidence that weekly skin assessments were completed for the weeks of 7/29, 8/5, 8/12, 8/19, 8/26/2024. Review of a progress note dated 8/31/2024 revealed the resident had a large fluid filled blister to his/her left shin, which was brought to the provider's attention and a treatment was implemented. During a surveyor interview on 9/5/2024 at 12:33 PM with the DNS she acknowledged that weekly skin assessments were not completed for Resident ID #9 for 5 consecutive weeks. Additionally, she revealed that skin assessments should be completed weekly per the facility policy and the resident's plan of care. b. Record review revealed that Resident ID #257 was admitted to the facility in August of 2024 with diagnoses including, but not limited to, cellulitis (a serious bacterial infection of the skin) and peripheral vascular disease. Review of a care plan dated 8/16/2024 revealed Resident ID #257 is at risk of skin impairment with an intervention including, but not limited to, conduct systemic skin inspections weekly and as needed and to document findings. Review of a skin assessment dated [DATE] revealed the resident had blisters to his/her abdominal folds. Further record review failed to reveal evidence that weekly skin assessments were completed for the weeks of 8/23 and 8/30/2024. During a surveyor interview on 9/6/2024 at 11:35 AM with the DNS she acknowledged that skin assessments were not completed for 2 weeks following the newly identified skin concerns on the resident's skin assessment dated [DATE]. Additionally, she revealed that the facility did not follow their policy or the resident's care plan relative to skin assessments.

Based on record review and staff interview it has been determined that the facility failed to ensure that all residents are free from significant medication errors for 1 of 1 resident reviewed relative to heparin (anticoagulant), Resident ID #48. Findings are as follows: Record review revealed that the resident was admitted to the facility in July of 2024 with diagnoses including, but not limited to, fracture of the right clavicle, fracture of the right ulna, fracture of the left femur and long-term use of anticoagulants (medications that prevent blood clots). Review of a hospital discharge summary dated 7/8/2024 revealed an order for heparin 5000 units per milliliter (ml), administer 1.5 ml to equal 7500 units total daily. Further review revealed a check mark next to the order indicating the order had been verified by the on-call Nurse Practitioner. Review of the physician orders revealed the order was inaccurately transcribed on 7/8/2024 as heparin 5000 units per ml, administer 1 ml to equal 5000 units total daily. After this error was identified by the surveyor and brought to the facility's attention the order was corrected on 9/4/2024 to administer 7500 units of heparin daily. During a surveyor interview on 9/5/2024 at 8:24 AM with the Director of Nursing Services (DNS) she acknowledged that the order was inaccurately transcribed as 5000 units versus the 7500 units ordered and the resident received received the wrong dose of heparin from 7/8/2024 until 9/4/2024.

46715 47279 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 failing to place residents on enhanced barrier precautions (EBP; involves using gown and gloves during high-contact resident care activities) for residents that require such for 3 of 5 residents reviewed with wounds, Resident ID #s 24, 28, and 267, and 1 of 2 residents reviewed for a Multi-Drug Resistant Organism (MDRO) infection, Extended Spectrum Beta Lactamase (ESBL), Resident ID #258. Findings are as follows: Review of a facility policy titled, Transmission Based Precaution Levels (Type of Infectious Condition, Techniques and Documentation) SNF [Skilled Nursing Facility] last modified on 6/6/2024, states in part, .Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with an MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds .[EBP] can be applied .to residents with any of the following: Wounds .regardless of MDRO colonization status .Would generally include chronic wounds .Example of chronic wounds (pressure sores, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers) .[EBP] .Gloves & Hand Washing Hand Sanitizer .Required .Gown .high contact resident care activities include dressing, bathing/showering, transferring, providing hygiene, changing briefs or assisting with toileting, device care or use, and wound care . 1a) Record review revealed that Resident ID #24 was admitted to the facility in June of 2023 with a diagnosis including, but not limited to, heart failure. Record review revealed the resident has a left upper arm skin graft (a type of surgery where providers take healthy skin from one part of the body and move it. The healthy skin covers or replaces skin that is damaged or missing) and receives a dressing change for wound care every other day. During multiple surveyor observations throughout the survey process from 9/3 through 9/5/2024 failed to reveal evidence of a isolation cart or signage posted outside of his/her room to indicate that s/he requires EBP due to his/her wound. During a surveyor interview on 9/5/2024 at 12:17 PM with the Director of Nursing Services (DNS), she acknowledged the resident was not on EBP. During a surveyor observation on 9/6/2024 at 11:47 AM, the resident was still not observed to be on EBP and did not have an isolation cart nor signage posted outside of his/her room despite being brought to the attention of the DNS by the surveyor on previous day. 1b) Record review revealed that Resident ID #28 was admitted to the facility in March of 2021 with diagnoses including, but not limited to, pressure ulcer of right buttock, stage 2 (an open wound that affects both top and bottom layers of the skin), and pressure induced deep tissue damage to the left ankle, left heel, and an unspecified site. Review of a wound consultation document dated 9/5/2024 revealed that the resident has wounds to his/her bilateral buttocks, left heel, left 5th toe, peri-area, and left lateral foot. Additionally, the resident is actively being treated for each wound. During multiple surveyor observations throughout the survey process from 9/3 through 9/5/2024 failed to reveal evidence of a isolation cart or signage posted outside of his/her room to indicate that s/he requires EBP due to his/her wounds. 1c) Record review revealed that Resident ID #267 was admitted to the facility in June of 2024 with a diagnosis including, but not limited to, diabetes mellitus with a foot ulcer. Record review revealed that the resident has a wound to his/her left heel that requires a daily dressing change and is actively being treated. During multiple surveyor observations throughout the survey process failed to reveal evidence of a isolation cart or signage posted outside of his/her room to indicate that s/he requires EBP due to his/her left heel wound. During a surveyor interview on 9/4/2024 at 11:35 AM with Licensed Practical Nurse, Staff B, she acknowledged that the resident has a wound to his/her left heel. During a surveyor interview on 9/5/2024 at 10:34 AM with the DNS in presence of the Infection Preventionist, she revealed that she would expect that residents with open wounds to be on EBP. She was unable to explain why the Resident ID #s 24, 28 and 267 were not on EBP. 2) Record review revealed that Resident ID #258 was readmitted to the facility in August of 2024 with diagnoses including, but not limited to, urinary tract infection and ESBL resistance. Review of the hospital discharge summary dated 8/23/2024 revealed that the resident was admitted for management of a urinary tract infection. Additionally, it indicated that the urine cultures were positive for ESBL. During multiple surveyor observations throughout the survey process from 9/3 through 9/4/2024 failed to reveal evidence of a isolation cart or signage posted outside of his/her room to indicate that s/he requires EBP due to his/her history of ESBL in his/her urine. During a surveyor interview on 9/4/2024 at 12:10 PM with the DNS, she acknowledged that the resident was not on EBP. During a follow up surveyor interview on 9/5/2024 at 12:10 PM with the DNS, she revealed that the resident was now placed on EBP. Additionally, she was unable to explain why Resident ID #258 was not placed on EBP due to his/her history of ESBL in his/her urine prior to being brought to the facility's attention by the surveyor.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receive the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 1 resident reviewed for Negative-Pressure Wound Therapy, (vacuum assisted closure, a therapeutic technique using a suction pump, tubing, and a dressing to remove excess drainage and promote healing in acute or chronic wounds), Resident ID #254. Findings are as follows: a. Review of a policy titled Wound Vac (Negative Pressure Wound Therapy) states in part, .Wound Vac therapy requires an order from the attending physician/nurse practitioner and will include the following: a) Exact location of placement and number of hours per day that the Wound vac should be activated. (Recommended 22 to 24 hours per day). And therapy setting (Continuous or intermittent) b) Type of dressing to be used, either black foam dressing or white soft foam dressing and size of dressing (small, medium, large, or extra large), and any adjunct dressing to be used . Record review revealed that the resident was readmitted to the facility in August of 2024 with diagnoses including, but not limited to, acute hematogenous osteomyelitis of the right tibia and fibula (an infection in the bone that typically spreads through the bloodstream), pressure ulcer of the right hip stage 3 (full-thickness skin loss, potentially exposing the subcutaneous tissue), and pressure ulcer of the sacral region stage 4 (the most severe type of pressure ulcers extending below the subcutaneous fat into deep tissues, including muscle, tendons, and ligaments). Record review revealed a physician's order for wound vac therapy with a start date of 8/24/2024, Wound Vac/Negative Pressure Wound Therapy: Apply to right lower extremity after cleansing with NS [normal saline]. Change three times per week. On 24hrs/day @ [at] 125 mmhg [millimeters of mercury] continuous. May disconnect for care and transport. Re-apply if dislodged. every day shift every Tue, Thu, Sat . Record review revealed that the resident had an appointment at the wound clinic on 8/30/2024 and returned to the facility with recommendations to cleanse the wound with normal saline, pat dry, cover the tendon with adaptic (petroleum based wound dressing) and apply foam over the wound bed, apply suction at 120-125 hhmg and to change the dressing three times a week. Record review of a progress note dated 8/30/2024, following the wound clinic appointment, revealed that the provider approved the recommendation to apply adaptic to the tendon. Additional record review failed to reveal evidence that the order for the wound vac therapy was updated after Resident ID #254's wound clinic appointment on 8/30/2024 to include the addition of adaptic to the tendon. Further review of the order for the wound vac therapy failed to reveal evidence of the type of foam to apply to the wound bed as indicated per the facility policy. b. Review of a policy titled Wound Vac (Negative Pressure Wound Therapy) states in part .apply gloves remove any dressing and remove any drainage .inspect the wound for any changes in condition, and measure the site as needed. Remove gloves .apply sterile gloves . Review of the Continuity of Care form dated 8/21/2024 from the hospital revealed that the resident tested positive for Methicillin Resistant Staphylococcus Aureus (MRSA; an organism that is resistant to antibiotics) on 8/9/2024 in the right ankle pressure wound. During a surveyor observation on 9/3/2024 at approximately 1:45 PM with Licensed Practical Nurse (LPN) Staff A and the Staff Educator/Infection Preventionist, revealed that the resident was on contact precautions and required the use of a gown and gloves upon entry to the room. After doning gloves, Staff A initiated wound care to the right ankle pressure wound. She removed the resident's wound vac soiled dressing and foam from the right lower extremity wound, and, without changing her soiled gloves, she then proceeded to cut the foam for the wound dressing with scissors, dressed the wound, touched the wound vac machine to turn it on and reached into her pocket to find a pen, never having removed her soiled gloves. During a surveyor interview immediately following the above observation with Staff A, she acknowledged that she did not change her gloves after removing the soiled dressing and proceeded to touch multiple clean surfaces and apply a clean dressing to the wound. c. Review of a policy titled Wound Vac (Negative Pressure Wound Therapy) states in part .apply gloves remove any dressing and remove any drainage .inspect the wound for any changes in condition, and measure the site as needed .wound observation necessary to monitor progress and document appropriately . Record review of a skin assessment completed on 8/21/2024 indicated the resident had 3 pressure ulcers. Record review revealed a care plan dated 8/22/2024 indicating that the resident had 3 pressure ulcers with interventions to include, but are not limited to, assess and document on the status of the pressure ulcers weekly and as needed. Record review failed to reveal measurements or documentation of the status of the pressure ulcers for two weeks following the skin assessment dated [DATE], to include, but is not limited to, shape, edges, wound bed, condition of surrounding tissues, signs of infection or possible complications, pain, and drainage as required per the regulation. Additional record review failed to reveal evidence that the care plan was followed relative to assessing and documenting the status of the pressure ulcers weekly. d. Review of a policy titled Wound Vac (Negative Pressure Wound Therapy) states in part .Assure proper treatment according to physician order. If procedure cannot be completed document reasons in appropriate records . Record review revealed the following physician orders: - Wound Vac; apply to right lower extremity after cleaning with normal saline, change three times a per week at 125 mmhg continuous. change every Tuesday, Thursday, and Saturday. - Clean left buttocks wound with normal saline pat dry apply Biostep (a collagen wound treatment) to wound bed and cover with a foam dressing with a start dated of 8/23/2024. - Clean left hip pressure wound with normal saline apply medihoney (wound gel) to the wound and cover with a foam dressing with a start date of 8/22/2024. - Cleanse pressure ulcer on sacrum with normal saline pat dry, apply Medihoney, and cover with an Allevyn foam dressing daily with a start date of 8/22/2024. Review of the August 2024 Treatment Administration Record (TAR) revealed the following dates that the treatments were not documented as completed and were left blank on the TAR: - Sacrum 8/23, 8/26, and 8/31/2024 - Left hip 8/23, 8/26 and 8/31/2024 - Left buttock 8/23, 8/26 and 8/31/2024 - Wound Vac 8/31/2024 Review of the September 2024 TAR revealed the following dates that the treatments were not documented as completed and were left blank on the TAR: - Sacrum 9/1/2024 - Left hip 9/1/2024 - Left buttock 9/1/2024 Record review failed to reveal evidence that the wound treatments were completed or refused by the resident on the above dates in August and September 2024. During surveyor interviews on 9/4/2024 at 12:13 PM, 9/5/2024 at 11:57 AM and 9/6/2024 at 11:08 AM with the Director of Nursing Services she acknowledged that the above mentioned wound treatments were not documented as being completed or refused on 8/23, 8/26, 8/31/2024, and 9/1/2024. Additionally, she revealed that she would have expected the staff to change their gloves after removing a soiled dressing. Furthermore, she revealed that she would expect the nurse to update the treatment orders as ordered by the provider. Lastly, she revealed that she would expect weekly documentation for pressure wounds to include measurements and the characteristics of the wound and she acknowledged that there was no evidence in the records of description of the wounds.

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 was offered the influenza and pneumococcal vaccinations or that they either received or did not receive the influenza or pneumococcal vaccination due to medical contraindications or refusal for 4 of 5 residents reviewed, Residents ID #s 1, 2, 4 and 5. Findings are follows: The Rhode Island Department of Health received a community reported complaint on 1/2/2024 which alleges in part, . [Resident ID #1] never received proper vaccinations that were supposed to be administered weeks earlier. Many residents have yet to receive vaccinations that were scheduled to be issued. According to the Centers for Disease Control and Prevention (CDC) pneumococcal vaccination is recommended for all adults 19 through [AGE] years old who have certain chronic medical conditions or are [AGE] years or older who have only received PPSV23 [23 vaccination], the PCV13 [type of pneumococcal conjugate vaccine] or PCV20 [type of pneumococcal conjugate vaccine] dose should be administered at least one year after the most recent PPSV23 vaccination. For adults [AGE] years or older who have received PCV13 and PCV23 PCV13 [type of pneumococcal conjugate vaccine] and 1 dose of PPSV23, administer PCV20. Record review of the facility's policy titled Pneumococcal Vaccination (Resident) states in part, .Immunization against the pneumococcal virus will be documented by the facility for each resident per ACIP [Advisory Committee on Immunization Practices] Guidelines. Documentation of immunization will be placed in the individual's record at the facility .The Unit Manager/designee will notify the physician of the admission/re-admission visits or as appropriate to determine eligibility for immunization .The Unit Manager/designee will educate the responsible party .of the pneumococcal vaccine(s) .and will complete the Resident Pneumococcal Vaccination Consent/Declination form .Once the consent is obtained by the resident/responsible party, the physician will provide the order for the resident to receive the appropriate clinically indicated pneumococcal vaccine(s) .A master log of all immunization/vaccine administration will be maintained in medical record . Record review of the facility's policy titled, Influenza Immunization (Residents) Policy states in part, .Annually, the facility will notify all residents and/or responsible parties, that immunizations against the Seasonal Influenza Virus will be arranged and provided as quantities permit .Prior to administration, residents and or/responsible parties will be educated regarding the risk and benefits of the influenza vaccine. Influenza vaccines will be administered no later than November 30th of each year or as soon as solution becomes available unless otherwise ordered by the physician. All new admissions will be offered the immunization during influenza season .A master log of all immunizations/vaccine administration will be maintained in the medical record .For residents that received influenza vaccines from other than facility staff, historical documentation will be completed on the master log in the medical record .If a resident is not immunized, the reason will be documented on the resident Influenza Vaccination Consent/Declination form .in the medical record .The Infection Preventionist will maintain a master log for all residents, documenting their immunization status for the influenza vaccine . During a surveyor interview on 1/3/2024 at 11:58 AM with the Director of Nursing Services (DNS), she acknowledged that the Influenza and Pneumococcal vaccinations have not been given to all residents. She revealed a Vaccination Consent/Declination form for the above immunizations was completed for each resident residing in the facility, in October of 2023. She further revealed that a review of the facility residents' vaccinations was completed in October of 2023 and the appropriate pneumococcal vaccine should have been administered to the residents. Additionally, the DNS revealed for newly admitted residents, a vaccination history and the Consent/Declination form would be completed within 72 hours of their admission and appropriate immunizations would be offered. 1. Record review revealed Resident ID #1 was admitted to the facility in September of 2019. S/he had medical diagnoses including, but not limited to, end stage renal disease, dependence on renal dialysis and Respiratory Syncytial Virus (RSV-respiratory infection). Record review of the resident's Immunization record revealed that s/he had previously received the PCV13 vaccine on 7/20/2015 and the PPSV23 vaccine on 11/4/2013. Further record review of the Vaccination Review: Consent/Declination Resident Form, dated 10/19/2023, revealed the resident had consented to receive the additional pneumococcal vaccination, PCV20. Additional record review of the resident's immunization record failed to reveal evidence that the PCV20 was administered. 2. Record review revealed Resident ID #2 was admitted to the facility in December of 2023 with diagnoses including, but not limited to, RSV infection, pneumonia and acute respiratory failure with hypoxia (low oxygen level). Record review of the resident's immunization record failed to reveal evidence that s/he had received the influenza or pneumococcal vaccination. Additionally, the record failed to reveal evidence that the influenza vaccine or the PPSV23 or PCV20 was offered, received, or declined. 3. Record review revealed Resident ID #4 was admitted to the facility in November of 2023 with diagnoses including, but not limited to, heart failure, diabetes mellitus and RSV infection. Record review of the resident's immunization record failed to reveal evidence that s/he had received the influenza or pneumococcal vaccination. Additionally, the record failed to reveal evidence that the influenza vaccine or the PPSV23 or PCV20 was offered, received, or declined. 4. Record review revealed Resident ID #5 was initially admitted to the facility in October of 2023 and readmitted in December of 2023. S/he had medical diagnoses including, but not limited to, RSV infection and acute respiratory failure with hypoxia. Record review of the resident's immunization record failed to reveal evidence that s/he had received the influenza or pneumococcal vaccination. Additionally, the record failed to reveal evidence that the influenza vaccine or the PPSV23 or PCV20 was offered, received, or declined. During a surveyor interview with the DNS on 1/3/2024 at 4:50 PM, she was unable to provide evidence that Resident ID #s 2, 4 and 5's medical records included documentation of a completed Vaccination Consent/Declination form for the above-mentioned immunizations or that the residents were offered, received, or declined the influenza and pneumococcal vaccines. Additionally, she was unable to provide evidence that the PCV20 vaccine had been administered to Resident ID #1, after s/he consented to receive it.

Based on record review, resident and staff interviews it has been determined that the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 1 resident reviewed for adverse medication reactions and following physicians' orders for specialist medical appointments, Resident ID #36 and 1 of 1 resident reviewed for Hospice Services, Resident ID #21. Findings are as follows: 1a. Review of a facility policy titled, Allergy Notification dated 9/25/2018, states in part, Harmful unintended reactions to medicines, foods and to items in the environment are called adverse drug, food or environmental reactions or allergic reactions .To help ensure that adverse allergy reactions for a resident are not overlooked, the allergy design within the EMR [Electronic Medical Record] provides a structured format for users to document and monitor resident allergies .The allergies will be listed on the front cover of the medical record or computerized listing will be available in the medical record for reference . Record review revealed that Resident ID #36 was admitted to the facility in December of 2022 with diagnoses including, but not limited to, history of urinary tract infections (UTIs) and dysuria (painful urination). Review of a community report complaint received by the Rhode Island Department of Health on 9/21/2023 alleges that Resident ID #36 was treated with an antibiotic, Invanz (Ertapenem Sodium) for a UTI from 9/2/2023, 9/6/2023, and by 9/7/2023 the resident had confusion and hallucinations. Additionally, the allegation revealed that the resident had received the same antibiotic previously with a similar reaction of confusion and hallucinations. The antibiotic had not been added to the resident's allergy list to alert the provider or pharmacy of the adverse reaction. Review of the Highlights of Prescribing Information for Invanz by Merck Pharmaceuticals revealed rare adverse reactions including, altered mental status, such as aggression, delirium, and hallucinations. Review of the February 2023 Medication Administration Record (MAR) revealed the resident received INVanz Solution Reconstituted 1 GM [gram] (Ertapenem Sodium, antibiotic) Inject 1 gram intramuscularly [IM] one time a day for infection for 7 Days from 2/22-2/25/2023. Review of the progress notes from February 2023 revealed the following: 2/23/2023 at 2:16 PM: .Pt [patient] shows apprehension towards IM antibiotic but allowed to be given on L [left] upper arm . 2/26/2023 at 2:09 AM: Socially Inappropriate/Disruptive: Noisiness/ Screaming. Resisted Care: Resisted ADL [activities of daily living] care. Paranoid Behaviors: Suspiciousness/ Fearfulness. Paranoid Behaviors: Hallucinations - Details of hallucinations: Seeing children in room. stated that they came out of [his/her] gut calling out names and yelling hello . 2/26/2023 at 5:33 AM: Pt refusing care this am. Insisting on sitting on side of bed. Demanding to get in chair but when approached to assist refuses assistance. Pt hallucinating 'bats all over [his/her] room and two babies sitting on the end of [his/her] bed . 2/26/2023 at 8:46 AM: Res [resident] continues with hallucinations this morning: Cats and dogs in room and two babies on the dresser. Called [sic] placed to covering MD [Medical Doctor], [name redacted], rec'd [received] n.o. [new order] .D/C'd [discontinued] Invanz. 2/27/2023 at 3:14 AM authored by the Physician, Staff C: Patient was reported to have some hallucination. Invanz IM discontinued . Record review of the September 2023 MAR revealed the resident received INVanz Solution Reconstituted 1 GM (Ertapenem Sodium) Inject 1 gram intramuscularly in the morning for UTI for 5 Days from 9/2/2023 until 9/6/2023. Review of the progress notes from September 2023 revealed the following: 9/8/2023 at 6:16 PM: Spoke with daughter [name redacted] about concerns of her [parent] being so confused and being alarmed there is no intervention being done about this. 9/10/2023 at 8:18 AM: Resident very restless, trying to get oob [out of bed] multiple times stating [s/he] wants to walk to the bathroom, also that [s/he] is going to the hospital for a test. staff tried to reorient and redirect [him/her] to stay in bed as [s/he] cannot ambulate the way [s/he] thinks [s/he] can, attempts unsuccessful. 9/11/2023 at 4:31 PM revealed that the nurse added Invanz to the resident's allergy list as the daughter indicated that the resident had a change in mental status after his/her last administration of the antibiotic. During a surveyor interview on 9/21/2023 at 2:21 PM with the resident's daughter, she revealed that the resident was having hallucinations following the administration of the Invanz and that the same had occurred when s/he received the medication previously in February. During a surveyor interview on 9/22/2023 at 9:55 AM with the resident, s/he revealed that s/he received an antibiotic to treat a urinary tract infection and it caused hallucinations. Additionally, s/he revealed that s/he had been told that the same reaction occurred when s/he took the same antibiotic at the beginning of the year. During a surveyor interview on 9/22/2023 at 11:10 AM with Licensed Practical Nurse (LPN), Staff D, she revealed that the resident was on Invanz for a urinary tract infection and was having bizarre hallucinations such as, his/her grandchild being under his/her bed, talking to the ceiling and to people that were not there. Additionally, Staff D revealed that the resident appeared to be suffering severe mental anguish and distress. Staff D revealed that she had remembered this behavior occurred once before during another treatment (February) for a UTI and when she looked up the medication, [s/he] had also been on Invanz at that time During a surveyor interview on 9/22/2023 at 10:44 AM with the Physician, Staff C, he revealed that he would have expected the staff to add the adverse medication reaction to the allergy list on the resident's face sheet. Additionally, he revealed that he would not have ordered the same antibiotic if it had been marked on his/her medical record. During a surveyor interview on 9/22/2023 at 10:57 AM with the Interim Director of Nursing Services (DNS), she revealed that she would have expected the adverse medication reaction to be added to the allergy list, to alert the physician and pharmacy to not order it. Additionally, she was unable to provide evidence that the facility provided treatment and care in accordance with professional standards of practice by administering a medication with a known previous adverse reaction. 1b. Record review revealed a physician's order with a start date of 3/10/2023 for a urology consult due to recurrent urinary tract infections. Review of a care plan for elimination revealed the resident has a history of UTIs with interventions including, but not limited to, urology consult as ordered. Review of a progress note dated 3/14/2023 at 11:10 AM revealed an appointment scheduled for a urology consult for 4/13/2023. Review of a progress note dated 4/5/2023 at 3:04 PM revealed the urology consult would be rescheduled to 6/26/2023. Record review revealed a fax cover sheet from the urology provider that states, We have no record that [s/he] was seen 6/26/2023. Record review failed to reveal evidence regarding the resident not attending his/her urology consult on 6/26/2023. Record review of a Lab Results Report dated 9/1/2023, revealed the resident was positive for a UTI. During a surveyor interview on 9/22/2023 at 10:44 AM with the Physician, Staff C he revealed that he was unaware that the resident did not attend his/her urology appointment and still wants the resident to have a urology consult. During a surveyor interview on 9/22/2023 at 11:36 AM with a Receptionist at the urology provider, she revealed that the resident was a no call, no show for the appointment and that no one from the facility or family cancelled the appointment. During a surveyor interview on 9/22/2023 at 10:57 AM with the Interim DNS, she was unable to provide evidence that the resident was seen by a urologist as ordered and per his/her care plan. 2. Record review revealed Resident ID #21 was admitted to the facility in March of 2020 with diagnoses including, but not limited to, unspecified dementia and generalized anxiety disorder. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating moderately impaired cognition. Record review revealed the resident was admitted to hospice services in November of 2021. Review of the resident's care plan revealed a focus area dated 4/2/2020, which revealed the resident has the potential for mood alteration due to his/her diagnoses, and is evidenced by periodic tearfulness, anxious mood, restlessness, paranoid ideation, expressions of suicidal ideation or hopelessness, and medication refusals. Additionally, it was revised on 6/2/2023, to state, Ongoing anxious and restless mood observed. Not always easily redirected. Continue with current plan of care. Interventions include but are not limited to, document mood, behavior status, and changes to the physician as needed. Review of the resident's progress notes revealed a note dated 8/29/2023 which states, Behavior: Pt [patient] awake most of the night, rang call bell approx 20 times during the night, repeated questions 'Am I gonna die', 'Am I gonna live', 'What tests are they running on me'. Intervention : Multiple attempts to answer pt's questions and offer reassurance. Brought pt several glasses of gingerale and adjusted bedding nurmerous [sic.] times. Pt denied pain/disc. Response : Behavior continued, pt seemed paranoid, anxious, stating 'Let me see your face, are you telling the truth? I see your eyes, I think that's a lie'. Review of a document titled, HOSPICE CARE COORDINATION NOTE, dated 8/29/2023 states in part, .Spoke with .Floor staff who verbalize PT has been increasingly anxious, specifically at night where it keeps [him/her] up as [s/he] is fearful of dying in [his/her] sleep. Spoke with ADNS [Assistant Director of Nursing] who verbalized she is going to call MD [Medical Doctor] to reinstate Ativan [used to treat anxiety disorders] . Further review of the HOSPICE CARE COORDINATION NOTE dated 8/29/2023 revealed a recommendation to restart Ativan 0.5 milligrams every 12 hours, as needed, for anxiety and agitation. Further review of the resident's progress notes revealed a note dated 8/29/2023 which states, Resident seen by hospice RN [Registered Nurse] today. New recommendation to reinstate ativan 0.5mg [every 12 hours as needed] anxiety/agitation. ADON [Assistant Director of Nursing] reaching out to MD. Record review failed to reveal evidence that the recommendation for Ativan was addressed or implemented by the physician. Review of a behavior monitoring form dated 9/3/2023 at 8:55 PM, revealed the resident was displaying behavior symptoms such as, agitation restlessness, consistently picking or fidgeting with items or body parts, and repetitive babbling or perseverating on verbal phrases. It further revealed that non-pharmacological interventions were used, such as comfort visit and redirection, but were documented as being ineffective, with no change in behavior. Additionally, it revealed that no pharmacological intervention was used. Review of an additional behavior monitoring form dated 9/13/2023, revealed the resident was displaying behavioral symptoms on 9/13/2023 at 3:30 AM. S/he displayed behaviors such as restlessness and agitation, evidenced by the resident ringing his/her call bell for approximately two hours. Potentially contributing factors were documented as increased anxiety. It further revealed that non-pharmacological interventions were used, such as comfort visit, food or drink offered, and toileting but was documented as being ineffective, with no change in behavior. Additionally, it revealed that no pharmacological intervention was used. Review of the resident's behavior observation task revealed the following dates and times the resident displayed behaviors during the evening or night, following the recommendation for Ativan, such as verbal or physical aggression, social or sexually inappropriateness, withdrawn, anxiety, or refusal of care: - 9/2/2023 at 8:43 PM, documented as occurring more than once during the shift - 9/5/2023 at 9:37 PM, documented as occurring more than once during the shift - 9/7/2023 at 8:32 PM, documented as occurring more than once during the shift - 9/8/2023 at 8:52 PM, documented as occurring more than once during the shift - 9/15/2023 at 8:21 PM, documented as occurring more than once during the shift - 9/16/2023 at 7:41 PM, documented as occurring more than once during the shift - 9/18/2023 at 8:04 PM, documented as occurring more than once during the shift During a surveyor interview on 9/21/2023 at 10:23 AM, with LPN, Staff E, she revealed the resident is highly anxious and is very fixated on dying. She indicated these behaviors have been occurring for over a year and staff must constantly reassure him/her that death is not imminent. During a surveyor interview on 9/21/2023 at 10:53 AM, with the Physician, Staff F, she revealed that hospice recommendations are reported to the physician by the nursing staff. She indicated that the resident has displayed these behaviors in the past, but revealed she was not aware that the behaviors have returned. Additionally, she was unable to provide evidence that the hospice recommendation was addressed. During a surveyor interview on 9/21/2023 at 11:13 AM with the Interim DNS, she revealed that she was not aware of this recommendation and had not received it, prior to the surveyor bringing it to her attention. She further revealed that the resident and her family have refused Ativan in the past but was unable to provide evidence of any refusal or that the recommendation was addressed by the physician. 46539 46715

46715 Based on surveyor observation, record review, resident, and staff interviews, it has been determined that the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 3 residents reviewed for pain management, Resident ID #s 46 and 257. Findings are as follows: Per the American Nurses Association (ANA) Statement The Ethical Responsibility to Manage Pain and the Suffering It Causes (2018): Nurses have an ethical responsibility to relieve pain and the suffering it causes; Nurses should provide individualized nursing interventions; The nursing process should guide the nurse's actions to improve pain management; Multimodal and interprofessional approaches are necessary to achieve pain relief . Review of a facility provided policy titled Pain Management dated 2/3/2023 states in part, .If the resident's pain is not controlled by the current treatment regimen, the practitioner should be notified . 1. Record review for Resident ID #257 revealed s/he was admitted to the facility in September of 2023 with diagnoses including, but not limited to, osteomyelitis (bone infection), pressure ulcer of the sacral region stage 4 (stage 4 pressure ulcer is the most severe type of pressure ulcer. The skin is severely damaged, and the surrounding tissue begins to die. The underlying muscles or bone may also be damaged), pressure ulcer of the right buttocks stage 4, and pressure ulcer of the left buttocks stage 4. Review of a Brief Interview for Mental Status conducted on 9/18/2023 revealed the resident scored a 15 out of 15 indicating the resident is cognitively intact. Review of the care plan dated 9/14/2023 revealed the resident has pain or potential in an alteration in comfort related to a chronic physical disability, right hip infection, and pressure ulcers. It further has interventions which include, but are not limited to, report non-verbal or verbal signs and symptoms of pain promptly to the nurse, medicate prior to therapy and treatment procedures as needed, teach resident to request analgesics/non-pharmacological methods before pain becomes severe and clarify misconceptions about addictions to pain medications. Review of the September 2023 Medication Administration Record (MAR) revealed the following orders: -Oxycodone HCl tablet 5 milligram (MG) give 5 mg by mouth every 12 hours as needed for pain with a start date of 9/13/2023. -Acetaminophen (Tylenol) tablet 325 MG give 2 tablets by mouth every 4 hours as needed for discomfort with a start date of 9/13/2023. Record review failed to reveal a pain scale indicating when to administer each medication. Review of occupational therapy documents dated 9/14/2023, revealed the residents pain limits his/her functional activities and s/he complained of 8 out of 10 pain to his/her right hip. It further revealed that the resident would like to be premedicated 1 hour prior to therapy related to his/her pain. Review of the physical therapy documentation dated 9/18/2023 revealed that the resident's treatment was limited by 7 out of 10 right hip pain. Review of the progress notes revealed the following: -9/14/2023 at 2:44 PM .[complaint of] 7/10 [right] hip and lower back pain. Assessed by therapy today. Therapy recommends bed pump and scheduling oxycodone prior to [physical therapy] daily. OK'd by Dr . -9/17/2023 at 11:53 PM authored by Registered Nurse (RN) Staff H, .Resident refused dressing changes this evening. Stated, 'I need to be medicated with oxycodone first so if you can't give me oxycodone then I'll wait till tomorrow when I can have some oxycodone before your [sic] change the dressings.' Unable to medicate resident with oxycodone [related to] time parameters . -9/18/2023 at 7:45 AM authored by RN Staff I, .Pt. [patient] also questioning why Oxycodone order is [every] 12 [hours] as well. Pt. wants to take pain med before Therapy and prior to Dressing changes, however yesterday [s/he] [received] pain med [at] 10am [and] refused [dressing] changes on 3-11 shift because Oxycodone could not be admin. until 10pm. Pt. requesting to speak [with] Dr. [name redacted] regarding [his/her] medications. Advised to write down all [his/her] concerns so [s/he] will not forget any when speaking w/ Physician. Suggested to Pt. about administering Oxycodone [at] 6am, then [s/he] could have it again [at] 6pm before [dressing] changes. Pt. declined stating [s/he] wants to take 1 hour before Therapy. Pt. presently [complaint of] 8/10 post-op [right] hip pain, offered Tylenol 650mg and ice and agreeable, 0600am admin. Tylenol, reports Tylenol ineffective . -9/18/2023 at 4:11 PM authored by the social worker Staff J, .Reports [his/her] concerns related to Oxycodone order, prefers every 6hrs [hours] vs 12hrs due to pain level throughout the day . -9/18/2023 at 6:22 PM Facility spoke with the nurse practitioner regarding this resident's labs. -9/19/2023 at 4:49 PM authored by the social worker Staff J, .patient requesting update on Oxycodone order. Writer explained this department would not be able to answer however as mentioned on 9/18, writer advised Nursing department this morning during morning report. Patient did not accept how the orders are handled within this facility and proceeded to refer to other hospitals/nursing facility standards. Patient expressed being dissatisfied with writer's answers. Writer attempted to advise again that the NP [Nurse Practitioner] will be in the facility on 9/20 and that she would be able to address concerns further . Record review revealed that the facility contacted the provider on 9/18/2023 regarding lab results; however, they did not report the resident not getting his/her dressings changed due to pain. Review of a pain interview completed on 9/19/2023 revealed that this resident had pain in the last 5 days. It further revealed that the pain is documented as occasionally. Additionally, the document revealed that pain has limited the resident's day to day activities. Lastly, at the time of the interview the resident's pain intensity was a 7 out of 10. During a surveyor interview with the resident on 9/18/2023 at 12:15 PM, s/he revealed concerns related to medication management, specifically his/her oxycodone timing. The resident revealed that s/he is in pain often and specifically needs his/her oxycodone prior to therapy and dressing changes. S/he further stated staff told him/her to write down his/her concerns and to talk to the doctor on Wednesday 9/20/2023. During a surveyor interview on 9/20/2023 at 9:07 AM with RN, Staff K, he revealed that the resident has osteomyelitis and skin grafts and that can be incredibly painful. He further revealed that he would not delay treatment saying to write something down on a Monday to be addressed on a Wednesday. During a surveyor interview on 9/21/2023 at 8:30 AM with Staff I, she revealed that in report she was told on Sunday night 9/17/2023 the resident refused to have his/her dressing changes completed to his/her wounds due to pain and not having a pain medication available. She further revealed that on the morning of 9/18/2023 she advised the resident to write down all of his/her concerns so s/he could address them with the provider when she comes in. Lastly, she revealed she did not contact the physician related to the resident refusing the dressing changes due to pain. During a surveyor interview on 9/22/2023 at 11:58 AM with RN, Staff H, she revealed that on 9/17/2023 she cared for the resident on the evening shift. She revealed that the resident wanted to be premedicated prior to his/her dressing changes. She indicated that when she checked the MAR the oxycodone was every 12 hours and told the resident to wait until 10 PM and then she could premedicate him/her to complete the dressings. The resident revealed that taking the medication at 10 PM and then completing the dressing changes would be too late. She further revealed that she did not contact the physician related to the resident's pain causing him/her to refuse the dressing changes. During a surveyor interview with the Physician, Staff F, on 9/21/2023 at 10:29 AM, she revealed that the facility did not call her, or the on-call provider related to the pain the resident was experiencing. Additionally, she revealed that if the facility reaches out to providers related to pain, typically the on call provider will give a one time dose if needed. Lastly, she revealed she would have expected them to call and ask for a one-time dose on 9/17/2023 so the dressing change could be completed. During a surveyor interview on 9/20/2023 at 1:42 PM, with the Interim Director of Nursing Services (DNS), she revealed that she would have expected the nursing staff to reach out to the provider to report the resident's pain and inability to complete the wound dressing due to pain. Furthermore, she was unable to provide evidence the facility provided pain management to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences resulting in the resident not receiving care of his/her stage 4 pressure wound dressings on 9/17/2023. 2. Record review revealed that Resident ID #46 was admitted to the facility in May of 2022 with a diagnosis including, but not limited to, polyosteoarthritis (present when four or more joints in the body are painful and inflamed). Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 12 out of 15, indicating moderate cognitive impairment. Additionally, it revealed that the resident complained of occasional pain rating his/her pain a 6 out of 10. Review of a care plan dated 5/12/2022 revealed the resident has pain or has the potential for pain due to osteoarthritis. The care plan includes an intervention to report non-verbal or verbal signs and symptoms of pain promptly to the nurse and reassess and adjust plan to optimize pain relief as needed. Review of a progress note dated 9/17/2023 at 11:55 AM revealed, signs and symptoms of severe pain starting at lower back and affecting hips and bilateral lower legs. Unable to tolerate HOB [head of bed] elevated and sitting up to transfer. Reports pain subsides when not moving. Medicated with ES [extra strength] Tylenol and tramadol. Son in to visit and expressed concern regarding past back surgeries and requesting XRAYs. Awaiting orders from on call . Record review failed to reveal evidence of physician notification of increased pain. During a surveyor interview on 9/21/2023 at 9:58 AM with the resident in the presence of his/her son, s/he continued to complain of lower back pain radiating to his/her legs. During a surveyor interview on 9/21/2023 at 10:28 AM with Registered Nurse, Staff G, she revealed that the resident did complain of pain to his/her lower back that morning. Additionally, she revealed that she was unaware if x-rays had been performed or if the residents increased pain had been reported to the doctor. Review of a progress note dated 9/21/2023 at 12:40 PM stated in part, This writer spoke with [Doctor]. Pain management regime reviewed, New orders obtained for Aspercreme Patch Daily x 2 weeks to lower back; Resident has previously reported c/o [complaint of] pain to lower back, good effect or PRN [as needed] tramadol given. New orders obtained for X-RAY Spine . During a surveyor interview on 9/21/2023 at 1:01 PM with Licensed Practical Nurse (LPN), Staff D, revealed that the resident complained of increased pain on Sunday 9/17/2023 and stated that the pain was concerning. Additionally, she revealed that the resident was administered extra strength Tylenol without effect and Tramadol with little effect. Staff D, revealed that she did not report the change in pain to the doctor or request the x-rays that the resident and family requested. During a surveyor interview on 9/22/2023 at 10:44 AM with the Physician, Staff C, he revealed that the staff had not called him on 9/17/2023 to report an increase in back pain causing difficulty sitting up or transferring, until 9/21/2023, 4 days following the initial complaint. He indicated he did not receive communication regarding increased pain. During a surveyor interview on 9/21/2023 at 10:32 AM with the Interim DNS, she revealed that she would expect the nurse to call the doctor for new orders if a resident complains of increased pain. Additionally, she was unable to provide evidence that the facility provided pain management consistent with professional standards of practice and reporting a change in condition to the provider.

Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for adverse medication reactions, Resident ID # 36. Findings are as follows: Review of a facility policy titled, Allergy Notification dated 9/25/2018, states in part, Harmful unintended reactions to medicines, foods and to items in the environment are called adverse drug, food or environmental reactions or allergic reactions .To help ensure that adverse allergy reactions for a resident are not overlooked, the allergy design within the EMR [Electronic Medical Record] provides a structured format for users to document and monitor resident allergies .The allergies will be listed on the front cover of the medical record or computerized listing will be available in the medical record for reference . Record review revealed that Resident ID #36 was admitted to the facility in December of 2022 with diagnoses including, but not limited to, history of urinary tract infections (UTIs) and dysuria (painful urination). Review of a community report complaint received by the Rhode Island Department of Health on 9/21/2023 alleges that Resident ID #36 was treated with an antibiotic, Invanz (Ertapenem Sodium) for a UTI from 9/2/2023, 9/6/2023, and by 9/7/2023 the resident had confusion and hallucinations. Additionally, the allegation revealed that the resident had received the same antibiotic previously with a similar reaction of confusion and hallucinations. The antibiotic had not been added to the resident's allergy list to alert the provider or pharmacy of the adverse reaction. Review of the Highlights of Prescribing Information for Invanz by Merck Pharmaceuticals revealed rare adverse reactions including, altered mental status, such as aggression, delirium, and hallucinations. Review of the February 2023 Medication Administration Record (MAR) revealed the resident received INVanz Solution Reconstituted 1 GM [gram] (Ertapenem Sodium, antibiotic) Inject 1 gram intramuscularly [IM] one time a day for infection for 7 Days from 2/22-2/25/2023. Review of the progress notes from February 2023 revealed the following: 2/23/2023 at 2:16 PM: .Pt [patient] shows apprehension towards IM antibiotic but allowed to be given on L [left] upper arm . 2/26/2023 at 2:09 AM: Socially Inappropriate/Disruptive: Noisiness/ Screaming. Resisted Care: Resisted ADL [activities of daily living] care. Paranoid Behaviors: Suspiciousness/ Fearfulness. Paranoid Behaviors: Hallucinations - Details of hallucinations: Seeing children in room. stated that they came out of [his/her] gut calling out names and yelling hello . 2/26/2023 at 5:33 AM: Pt refusing care this am. Insisting on sitting on side of bed. Demanding to get in chair but when approached to assist refuses assistance. Pt hallucinating 'bats all over [his/her] room and two babies sitting on the end of [his/her] bed . 2/26/2023 at 8:46 AM: Res [resident] continues with hallucinations this morning: Cats and dogs in room and two babies on the dresser. Called [sic] placed to covering MD [Medical Doctor], [name redacted], rec'd [received] n.o. [new order] .D/C'd [discontinued] Invanz. 2/27/2023 at 3:14 AM authored by the Physician, Staff C: Patient was reported to have some hallucination. Invanz IM discontinued . Record review of the September 2023 MAR revealed the resident received INVanz Solution Reconstituted 1 GM (Ertapenem Sodium) Inject 1 gram intramuscularly in the morning for UTI for 5 Days from 9/2/2023 until 9/6/2023. Review of the progress notes from September 2023 revealed the following: 9/8/2023 at 6:16 PM: Spoke with daughter [name redacted] about concerns of her [parent] being so confused and being alarmed there is no intervention being done about this. 9/10/2023 at 8:18 AM: Resident very restless, trying to get oob [out of bed] multiple times stating [s/he] wants to walk to the bathroom, also that [s/he] is going to the hospital for a test. staff tried to reorient and redirect [him/her] to stay in bed as [s/he] cannot ambulate the way [s/he] thinks [s/he] can, attempts unsuccessful. 9/11/2023 at 4:31 PM revealed that the nurse added Invanz to the resident's allergy list as the daughter indicated that the resident had a change in mental status after his/her last administration of the antibiotic. During a surveyor interview on 9/21/2023 at 2:21 PM with the resident's daughter, she revealed that the resident was having hallucinations following the administration of the Invanz and that the same had occurred when s/he received the medication previously in February. During a surveyor interview on 9/22/2023 at 9:55 AM with the resident, s/he revealed that s/he received an antibiotic to treat a urinary tract infection and it caused hallucinations. Additionally, s/he revealed that s/he had been told that the same reaction occurred when s/he took the same antibiotic at the beginning of the year. During a surveyor interview on 9/22/2023 at 11:10 AM with Licensed Practical Nurse (LPN), Staff D, she revealed that the resident was on Invanz for a urinary tract infection and was having bizarre hallucinations such as, his/her grandchild being under his/her bed, talking to the ceiling and to people that were not there. Additionally, Staff D revealed that the resident appeared to be suffering severe mental anguish and distress. Staff D revealed that she had remembered this behavior occurred once before during another treatment (February) for a UTI and when she looked up the medication, [s/he] had also been on Invanz at that time During a surveyor interview on 9/22/2023 at 10:44 AM with the Physician, Staff C, he revealed that he would not have ordered the same antibiotic if it had been marked on his/her medical record. During a surveyor interview on 9/22/2023 at 10:57 AM with the Interim Director of Nursing Services (DNS) she was unable to provide evidence that the facility ensured a resident's drug regimen is free from unnecessary drugs by administering a medication with a known previous adverse reaction.

Based on surveyor obseratio, record review, resident and staff interviews, it has been determined that the facility failed to ensure that all licensed nurses have the specific skill sets necessary to care for residents' needs for 4 of 5 residents reviewed, relative to changes in condition, Resident ID #s 257, 46, 21, and 15. Findings are as follows: Review of a facility in-service titled, Change in Condition, Symptoms, or Signs, held on 6/26/2023, indicated a change in condition, symptoms, or signs include but are not limited to, pain, behavior symptoms, altered mental status, abnormal vital signs, and shortness of breath. 1. Record review revealed Resident ID #257 was admitted to the facility in September of 2023 with diagnoses including, but not limited to, osteomyelitis (infection in the bone), pressure ulcer of the sacral region stage 4 (stage 4 pressure ulcer is the most severe type of pressure ulcer. The skin is severely damaged, and the surrounding tissue begins to die. The underlying muscles or bone may also be damaged), pressure ulcer of the right buttocks stage 4, and pressure ulcer of the left buttocks stage 4. Review of the care plan dated 9/14/2023 revealed the resident has pain or potential in an alteration in comfort related to a chronic physical disability, right hip infection, and pressure ulcers. It further has interventions which include, but are not limited to, report non-verbal or verbal signs and symptoms of pain promptly to the nurse, medicate prior to therapy and treatment procedures as needed, teach resident to request analgesics/non-pharmacological methods before pain becomes severe and clarify misconceptions about addictions to pain medications. Record review revealed the resident complained of pain to staff on the following dates: -9/14/2023 -9/15/2023 -9/17/2023 -9/18/2023 -9/19/2023 -9/20/2023 Record review revealed that on 9/17/2023 the resident refused his/his wound dressings to be changed due to his/her pain. Record review revealed on 9/18/2023 at 6:22 PM, the facility contacted the nurse practitioner regarding the resident's lab results. Further record review failed to reveal evidence that pain medication was discussed with the nurse practitioner on 9/18/2023. During a surveyor interview with Resident ID #257 on 9/18/2023 at 12:15 PM, s/he revealed concerns related to medication management specifically his/her oxycodone timing. The resident revealed that s/he is in pain often and specifically needs his/her oxycodone prior to therapy and dressing changes. S/he further stated staff told him/her to write down his/her concerns and to talk to the doctor on Wednesday. During a surveyor interview on 9/21/2023 at 8:30 AM with Registered Nurse, Staff I, she revealed that on the morning on 9/18/2023 she advised the resident to write down all of his/her concerns so s/he could address them with the provider when she comes into the facility. Lastly, she revealed she did not contact the physician related to the resident's pain. During a surveyor interview on 9/22/2023 at 11:58 AM with Registered Nurse Staff H, she acknowledged the resident complained of pain and declined his/her dressing change on 9/17/2023. Additionally, she indicated she did not call they physician to report the resident's pain. During a surveyor interview with the Physician, Staff F on 9/21/2023 at 10:29 AM, she revealed that the facility did not call her, or the on-call provider related to pain. Additionally, she revealed she would have expected them to call and ask for a one-time dose and then monitor pain. During a surveyor interview on 9/20/2023 at 1:42 PM, with the Interim Director of Nursing Services (DNS), she revealed that she would have expected the nursing staff to reach out to the provider to report the resident's pain. 2. Record review revealed that Resident ID #46 was admitted to the facility in May of 2022 with a diagnosis including, but not limited to, polyosteoarthritis (present when four or more joints in the body are painful and inflamed). Review of a care plan dated 5/12/2022 revealed the resident has pain or has the potential for pain due to osteoarthritis. The care plan includes an intervention to report non-verbal or verbal signs and symptoms of pain promptly to the nurse and reassess and adjust the plan to optimize pain relief as needed. Review of a progress note dated 9/17/2023 at 11:55 AM revealed, signs and symptoms of severe pain starting at lower back and affecting hips and bilateral lower legs. Unable to tolerate HOB [head of bed] elevated and sitting up to transfer. Reports pain subsides when not moving. Medicated with ES [extra strength] Tylenol and tramadol. Son in to visit and expressed concern regarding past back surgeries and requesting XRAYs. Awaiting orders from on call . Record review failed to reveal evidence of physician notification of increased pain. During a surveyor interview on 9/21/2023 at 1:01 PM with Licensed Practical Nurse (LPN), Staff D, she revealed that the resident complained of increased pain on Sunday 9/17/2023 and stated that the pain was concerning. Additionally, she revealed that the resident was administered extra strength Tylenol without effect and Tramadol with little effect. Staff D revealed that she reported the resident's pain to the nursing supervisor, but did not report the change in pain to the doctor or request the x-rays that the resident and family requested. During a surveyor interview on 9/22/2023 at 12:44 PM with Registered Nurse, Staff L, she indicated that there is no real system in place for notifying the physician of a resident's change in condition, and indicated that sometimes things get lost. She further indicated that she is unclear what the process should be when reporting a resident's change in condition, and indicated that some staff notify the nursing supervisor and others notify the physician. During a surveyor interview on 9/22/2023 at 1:48 PM with Registered Nurse, Staff M, she revealed that she was the nursing supervisor on shift on 9/17/2023 when the resident complained of pain and indicated that she did not report the resident's change in condition to the physician. Additionally, she indicated that she is unclear what the process is for notifying a physician of a resident's change in condition. During a surveyor interview on 9/22/2023 at 10:44 AM with the Physician, Staff C, he revealed that the staff had not called him on 9/17/2023 to report an increase in back pain causing difficulty sitting up or transferring until 9/21/2023, 4 days following the complaint. He indicated he did not recieve communication regarding increased pain. During a surveyor interview on 9/21/2023 at 10:32 AM with the Interim Director of Nursing Services she revealed that she would expect the nurse to call the doctor for new orders if a resident complains of increased pain. Additionally, she indicated that a resident's change in condition should be reported to the physician and not to the nursing supervisor. 3. Record review revealed Resident ID #21 was admitted to the facility in March of 2020 with diagnoses including, but not limited to, unspecified dementia and generalized anxiety disorder. Review of the resident's progress notes revealed a note dated 8/29/2023 which states, Behavior : Pt [patient] awake most of the night, rang call bell [approximately] 20 times during the night, repeated questions 'Am I gonna die', 'Am I gonna live', 'What tests are they running on me'. Intervention: Multiple attempts to answer pt's questions and offer reassurance. Brought pt several glasses of gingerale and adjusted bedding nurmerous [sic.] times. Pt denied pain/ [discomfort]. Response: Behavior continued, pt seemed paranoid, anxious, stating 'Let me see your face, are you telling the truth? I see your eyes, I think that's a lie'. During a surveyor interview on 9/21/2023 at 10:23 AM, with Registered Nurse, Staff E, she revealed the resident is highly anxious and is very fixated on dying. She indicated these behaviors have been occurring for over a year and staff must constantly reassure him/her that death is not imminent. During a surveyor interview on 9/21/2023 at 10:53 AM, with the Physician, Staff F, she indicated that the resident has displayed these behaviors in the past, but revealed she was not aware that the behaviors have returned. During a surveyor interview on 9/21/2023 at 11:13 AM with the Interim Director of Nursing Services, she was unable to provide evidence that the resident's physician was notified of his/her change in condition related to behavioral symptoms. 4. Record review revealed Resident ID #15 was admitted to the facility in June of 2022 with a diagnosis including, but not limited to, left base infiltrate (viral infection that can cause abnormal substances to take residence in the respiratory system). Record review of a physician's order dated 8/31/2023 reveals Oxygen at 2L [Liter] via [through] NC [nasal cannula] as needed for SOB [shortness of breath] or Pulse Ox less than 90%. Record review of a progress note dated 9/11/2023 revealed, Activities came to nurses station to inform us that resident was very red and saying [s/he] couldn't breath and oxygen was off of [him/her]. I went and put it back on and took a set of vital signs .Oxygen increased to 3LNC since sats were at 89%. Will pass this on to evening nurse when she comes in shortly. During a surveyor observations of the resident on the following dates and times revealed s/he was receiving oxygen therapy through his/her nasal cannula at 3 liters per minute: -9/18/2023 at 9:19 AM -9/19/2023 at 2:14 PM -9/20/2023 at 8:12 AM -9/21/2023 at 9:39 AM During a surveyor interview with Licensed Practical Nurse, Staff E, on 9/21/2023 at 9:40 AM, she acknowledged that the resident was receiving 3 liters of oxygen via nasal cannula. Additionally, she could not provide evidence that the physician or nurse practitioner were informed of the resident's need for increased oxygen. During a surveyor interview with the Physician, Staff F on 9/21/2023 at 1:14 PM, she revealed that she would expect the nurse to inform her or the nurse practitioner if there was a change in the resident's condition. Additionally, she acknowledged that she was unaware that the resident required 3 liters of oxygen and would expect herself and/or the nurse practitioner to be notified. During a surveyor interview with the Interim Director of Nursing Services on 9/21/2023 at 12:43 PM, she revealed she would expect the nurse to have called the physician with the resident's change in oxygen requirements. Refer to F 697, F 684 and F 695.

Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality for 1 of 4 residents reviewed relative to wound assessments and following physician orders for skin checks, Resident ID #36. Findings are as follows: A. Record review revealed that the resident was admitted to the facility in December of 2022 with a diagnosis including, but not limited to, cellulitis of the right lower extremity. Review of a care plan for skin integrity revealed an intervention dated 12/20/2022 to conduct systemic skin inspections weekly, as needed, and document the findings. Review of a physician's order dated 8/9/2023 states, Skin Examination Report to RN [Registered Nurse] and document in Medical Record if new skin condition is identified. Weekly every Tuesday evening. Record review failed to reveal evidence that skin examinations were completed as ordered on the following dates 8/29, 9/5, 9/12 and 9/19/2023. This indicates that skin examinations had not been completed for 4 consecutive weeks. During a surveyor interview on 9/20/2023 at 1:17 PM with the Interim Director of Nursing Services (DNS) she acknowledged the 4 weeks of missing skin assessments per the care plan. Additionally, she was unable to provide evidence that the skin checks were performed per the physician's order. B. According to the Wound Care Education Institute, 2020, wound care documentation should be carried out weekly including type of wound, measurements, type of tissue, symptoms of infection, presence of drainage, wound edges, pain, and current treatment. Review of a care plan for skin integrity revealed the resident has a hematoma to his/her right posterior leg that opened on 7/6/2023. Review of the September 2023 Treatment Administration Record revealed a physician's order for wound care for his/her right lower extremity to include cleanse with normal saline, followed by Vaseline impregnated gauze to wound bed followed by ABD pad (Abdominal pad used for heavily draining wounds) and kling wrap daily. Review of a progress note dated 8/1/2023 at 3:01 PM revealed the resident and family had decided to go to a wound care center outside of the facility. Record review failed to reveal evidence of weekly documentation of wound measurements, type of tissue, presence of drainage or wound edges. Record review revealed only a weekly plan to include treatment orders and follow up appointments. During a surveyor interview on 9/20/2023 at 1:17 PM with the Interim DNS she revealed that the resident goes out to the wound clinic weekly. She failed to provide evidence of weekly wound documentation to include wound measurements, type of tissue, presence of drainage, or wound edges in the resident's medical record.

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 7 of 8 months reviewed and for 1 of 3 residents reviewed for antibiotic use, Resident ID #36. Findings are as follows: 1. Review of a facility provided policy titled Antibiotic Stewardship Program dated 1/29/2018, states in part .Purpose .the framework will result in more effective treatment of infections so that resident/patient outcomes are optimized. Appropriate antibiotic use will contribute to minimizing the risk of healthcare-associated infections, benefiting residents/patients, staff, services delivery and clinical outcomes .Policy: the facility antibiotic stewardship program will focus on improving antibiotic use while optimizing the treatment of infections and reducing the risk for possible adverse events associated with antibiotic use .Empirical antimicrobial therapy should be reviewed 48 hours after starting therapy, and no later than the 3rd day of treatment . Review of a community reported complaint received by the Rhode Island Department of Health on 9/21/2023 alleged that Resident ID #36 was treated with an antibiotic, Invanz (Ertapenem Sodium, antibiotic) for a urinary tract infection (UTI) from 9/2-9/6/2023 and by 9/7/2023 the resident had confusion and hallucinations. Additionally, the allegation revealed that the resident had received the same antibiotic previously with a similar reaction of confusion and hallucinations. The antibiotic had not been added to the antibiotic line list to alert the provider or facility of the adverse reaction. Review of the Highlights of Prescribing Information for Invanz by Merck Pharmaceuticals revealed rare adverse reactions including, altered mental status such as aggression, delirium, and hallucinations. Record review revealed that Resident ID #36 was admitted to the facility in May of 2020 with diagnoses including, but not limited to, history of urinary tract infections and dysuria (painful urination). Review of the February 2023 Medication Administration Record (MAR) revealed the resident received INVanz Solution Reconstituted 1 GM (Ertapenem Sodium, antibiotic) Inject 1 gram [GM] intramuscularly [IM] one time a day for infection for 7 Days from 2/22-2/25/2023. Review of the progress notes from February 2023 revealed the following: 2/23/2023 at 2:16 PM: .Pt [patient] shows apprehension towards IM antibiotic but allowed to be given on L [left] upper arm . 2/26/2023 at 2:09 AM: Socially Inappropriate/Disruptive: Noisiness/ Screaming. Resisted Care: Resisted ADL [activities of daily living] care. Paranoid Behaviors: Suspiciousness/ Fearfulness. Paranoid Behaviors: Hallucinations -Details of hallucinations: Seeing children in room. stated that 'they came out of [his/her] gut' calling out names and yelling hello . 2/26/2023 at 5:33 AM: Pt refusing care this am. Insisting on sitting on side of bed. Demanding to get in chair but when approached to assist refuses assistance. Pt hallucinating 'bats all over [his/her] room and two babies sitting on the end of [his/her] bed' . 2/26/2023 at 8:46 AM: Res [resident] continues with hallucinations this morning: Cats and dogs in room and two babies on the dresser. Called placed to covering MD, [name redacted], rec'd [received] n.o. [new order] .D/C'd [discontinued] Invanz. 2/27/2023 at 3:14 AM authored by the Physician Staff C: Patient was reported to have some hallucination. Invanz IM discontinued . Record review of the September 2023 MAR revealed the resident received INVanz Solution Reconstituted 1 GM (Ertapenem Sodium) Inject 1 gram intramuscularly in the morning for UTI for 5 Days from 9/2 throough 9/6/2023. Review of the progress notes from September 2023 revealed the following: 9/8/2023 at 6:16 PM: Spoke with daughter [name redacted] about concerns of her [parent] being so confused and being alarmed there is no intervention being done about this. 9/10/2023 at 8:18 AM: Resident very restless, trying to get oob [out of bed] multiple times stating [s/he] wants to walk to the bathroom, also that [s/he] is going to the hospital for a test. staff tried to reorient and redirect [him/her] to stay in bed as [s/he] cannot ambulate the way [s/he] thinks [s/he] can, attempts unsuccessful. During a surveyor interview on 9/22/2023 at 11:10 AM with Licensed Practical Nurse (LPN), Staff D, she revealed that the resident was on Invanz for a urinary tract infection and was having bizarre hallucinations such as, his/her grandchild being under his/her bed, talking to the ceiling and to people that were not there. Additionally, Staff D revealed that the resident appeared to be suffering severe mental anguish and distress. Staff D revealed that she had remembered this behavior once before during another treatment for a UTI and when she looked up the medication, s/he had also been on Invanz at that time. Review of the facility provided Antibiotic Stewardship Line Listing for 2023 failed to reveal evidence this resident was listed as receiving INVanz for the month of February 2023 and that the resident had an adverse reaction to the medication. This resulted in the resident receiving INVanz in September of 2023 and experiencing an increase in hallucinations, an adverse reaction for a second time. Record review failed to reveal evidence that the facility listed the resident on the antibiotic line list for the month of September 2023 with Invanz documented as an adverse reaction. During a surveyor interview on at 1:09 PM with the Interim Director of Nursing Services, she was unable to provide evidence that the facility provided an adequate antibiotic stewardship program that focused on improving antibiotic use while reducing the risk for possible adverse events related to this resident. 2. Review of the antibiotic stewardship monthly records failed to reveal complete documentation of tracking information for the months of January, February, March, April, May, June, August, and September 2023, which included, diagnostic tests including but not limited to laboratory results, x-ray, cultures, and test results to ensure the appropriate antibiotics are prescribed. Further review failed to reveal a system for monitoring or reviewing each resident's response to antibiotics. During a surveyor interview on 9/21/2023 at 9:57 AM with the Infection Preventionist, she failed to reveal evidence of completed documentation regarding antibiotic stewardship.

43376 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 or did not receive the pneumococcal vaccination due to medical contraindications or refusal, for 5 of 8 residents reviewed, Residents ID #'s 14, 15, 21, 30, and 40. Findings are follows: According to the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, Revised 2/3/2023 states in part, .The resident's medical record includes documentation that indicates, at a minimum, the following: .That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal . According to the Centers for Disease Control and Prevention (CDC) pneumococcal vaccination is recommended for all adults 19 through [AGE] years old who have certain chronic medical conditions or are [AGE] years or older who have only received PPSV23 [23 vaccination], the PVC15 [type of pneumococcal conjugate vaccine] or PVC20 [type of pneumococcal conjugate vaccine] dose should be administer at least one year after the most recent PPSV23 vaccination. For adults 19 through [AGE] years old who have certain chronic medical conditions 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 [type of pneumococcal conjugate vaccine], give PPSV23 or PCV20 as previously recommended. Record review of the facility's policy titled Pneumoccal Vaccination (Resident) states in part, .Immunization against the pneumococcal virus will be documented by the facility for each resident per ACIP [Advisory Committee on Immunization Practices] Guidelines. Documentation of immunization will be placed in the individual's record at the facility. If a resident is not immunized, the reason will be documented . 1. Record review of Resident ID #14 revealed the resident was admitted to the facility in September of 2019. Record review of the resident's immunization records failed to reveal evidence that the PPSV23 or PCV20 was offered, received, or declined. 2. Record review of Resident ID #15 revealed the resident was initially admitted to the facility in June of 2022. Record review of the resident's immunization records failed to reveal evidence that the PPSV23 or PCV20 was offered, received, or declined. 3. Record review of Resident ID #21 revealed the resident was admitted to the facility in March of 2020. Record review of the resident's immunization records failed to reveal evidence that the PPSV23 or PCV20 was offered, received, or declined. 4. Record review of Resident ID #30 revealed the resident was admitted to the facility in September of 2021. Record review of the resident's immunization records failed to reveal evidence that the PPSV23 or PCV20 was offered, received, or declined. 5. Record review of Resident ID #40 revealed the resident was admitted to the facility in November of 2020. Record review of the resident's immunization records failed to reveal evidence that the PPSV23 or PCV20 was offered, received, or declined. During a surveyor interview with the Infection Preventionist on 9/21/2023 at 11:43 AM, she was unable to provide evidence that Resident ID #s 14, 15, 21, 30, and 40 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. During a surveyor interview with the Interim Director of Nursing Services on 9/21/2023 at 1:56 PM, she was unable to provide evidence that the above residents were offered, received, or declined the second pneumococcal vaccine.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide care in accordance with a resident's comprehensive care plan for 1 of 2 residents, Resident ID #30 relative to aspiration. Findings are as follows: Record review revealed the resident was admitted to the facility in May of 2019 with diagnoses including. but not limited to, dysphagia (difficulty in swallowing) and unspecified dementia with other behavioral disturbances. Review of a Minimum Data Set assessment dated [DATE] revealed the resident requires extensive assistance of one staff member for eating. Additionally, it revealed the resident is totally dependent upon two staff members for transfers. Review of the resident's comprehensive care plan revealed a focus area initiated on 5/29/2019 and revised 8/21/2023, which revealed the resident is at risk for alteration in nutrition related to mental status, advanced age, dysphagia, and weight loss history. It further revealed that interventions include but are not limited to, aspiration precautions and out of bed for meals as able. Record review revealed the resident was being treated by speech therapy from 1/11/2023 to 1/25/2023, following a diagnosis of right lower lobe pneumonia, which was documented as potentially aspiration based. Review of a document titled, Speech Therapy Discharge Summary, dated 1/27/2023, states in part, .Training in maintaining upright position in the Broda chair as wel [sic.] to minimize aspiration risk .Swallow Strategies/Positions: To facilitate safety and efficiency, it is recommended the patient use the following strategies and/or maneuvers during oral intake .upright posture during meals and upright posture for [greater than] 30 min after meals . During a surveyor observation on 9/19/2023 at 9:10 AM, it was revealed the resident was in bed and was being assisted with eating breakfast by a Nursing Assistant (NA). During a surveyor interview on 9/19/2023 at 9:14 AM with NA, Staff A, she indicated that she did not know the resident but was told to feed him/her by the nurse. She revealed she had not yet received her assignment or information on the patients she will be caring for during that shift. During a surveyor interview on 9/19/2023 at 10:04 AM with Licensed Practical Nurse, Staff B, she indicated that she is aware that the resident should not be eating in bed, but revealed she told the NA to feed him/her in bed due to being short staffed. During a surveyor interview on 9/20/2023 at 1:48 PM with the Interim Director of Nursing Services, she revealed the resident should be out of bed during meals, per his/her comprehensive care plan.