Every finding on record at Alpine Nursing Home Inc

Based on clinical record review and staff interview, the facility failed to ensure the resident's medical record includes documentation that the resident either received the pneumococcal vaccination or did not receive the vaccination due to medical contraindications or refusal, for 3 of 3 resident's reviewed who had consented to the vaccination, Resident ID #s 39, 42 and 44.Findings are as follows:Review of a facility policy titled, Pneumococcal Vaccinations states in part, .The pneumococcal vaccine history of all residents will be established upon admission to the facility. the [pneumococcal Vaccine] will be offered to all eligible residents.within 5 days of their admission, depending upon their prior pneumococcal vaccine history.The residents and/or designated family members will be given a copy of the most recent vaccine information statement (VIS).The resident and/or designated family members will be given a consent form to sign prior to administration, stating they have read the VIS and wish to receive the specific pneumococcal vaccine to be administered.1. Record review for Resident ID #39 revealed the resident was readmitted to the facility in August of 2025.Record review of a document dated 9/11/2025, titled Consent for Vaccinations: Flu, Pneumococcal, RSV (respiratory syncytial virus), Covid revealed that the resident consented to have the pneumococcal vaccination administered.2. Record review for Resident ID #42 revealed the resident was admitted to the facility in January of 2026.Record review of a document dated 1/21/2026, titled Consent for Vaccinations: Flu, Pneumococcal, RSV (respiratory syncytial virus), Covid revealed that the resident's responsible party consented to have the pneumococcal vaccination administered.3. Record review for Resident ID #44 revealed the resident was admitted to the facility in August of 2025.Record review of a document dated 10/8/2025 titled Consent for Vaccinations: Flu, Pneumococcal, RSV (respiratory syncytial virus), Covid revealed that the resident's responsible party consented to have the pneumococcal vaccination administered.Record review failed to reveal evidence that the pneumococcal vaccine was administered to the above residents, per the signed consents.During a surveyor interview on 7/10/2026 at 11:24 AM, with the Infection Preventionist, she acknowledged that consents were signed and the residents should receive the pneumococcal vaccine.During a surveyor interview on 7/10/2026 at approximately 11:10 AM, with the Director of Nursing Services, she was unable to provide evidence that the pneumococcal vaccine was given to the above residents.

Based on clinical record review and staff interview, the facility failed to inform the resident or the resident's appointed representative, in advance, of the care to be furnished by the physician or other provider, of the risks and benefits of proposed care or treatment alternatives relative to the ordering of, and administration of, psychotropic medications (a prescription drug designed to alter brain chemistry thus affecting a person's mind, emotions, and behavior) for 5 of 5 residents reviewed for unnecessary medications, Resident ID #s 1, 3, 4, 5 and 30, and for 1 of 1 resident reviewed for mood and behavior, Resident ID #28.Findings are as follows:A. Record review revealed Resident ID #1 was readmitted to the facility in January of 2026 with diagnoses including, but not limited to, adjustment disorder and major depressive disorder.Review of a care plan focus area, last revised on 6/22/2026, revealed Resident ID #1 utilizes high risk medications, including anti-anxiety medications.Record review revealed the resident was prescribed and subsequently administered the following psychotropic medication:-6/3/2026 through 8/3/2026: Ativan (lorazepam) with instructions to administer 0.5 milligrams (mg) once daily as needed.Record review failed to reveal evidence the resident and/or representative were informed, in advance, of the addition of a new psychotropic medication to the resident's medication regimen, prior to initiating therapy, for the above psychotropic medication. Additionally, record review failed to reveal evidence that the resident and/or resident's representative was informed of the risks and benefits, side effects, and/or treatment alternatives.B. Record review revealed Resident ID #3 was readmitted to the facility in August of 2025 with diagnoses including, but not limited to, generalized anxiety disorder, delusional disorders, and major depressive disorder.Review of a care plan focus area, last revised on 5/7/2026, revealed that Resident ID #3 receives psychotropic medications and is at risk for side effects, adverse drug reactions, and oversedation.Record review revealed the resident was prescribed and subsequently administered the following psychotropic medications:-5/1/2025: Quetiapine tablet; 25 mg, with instructions to administer once daily at bedtime-8/21/2025: Quetiapine tablet; 25 mg, with instructions to administer once daily-8/21/2025: Sertraline 100 mg, with instructions to administer 100 mg with a 25 mg tablet to equal a total dose of 125 mg-8/21/2025: Sertraline 25 mg, with instructions to administer with 100 mg tablet to equal a total dose of 125 mg-4/3/2026: Mirtazapine 7.5 mg tablet, with instructions to administer 15 mg at bedtimeRecord review revealed a document titled, ALPINE PSYCHOTROPIC MEDICATION CONSENT FOR USE AND TREATMENT, dated 3/6/2025, states in part, .At admission and at any time after that the prescribing physician or nurse practitioner may order a medication that is classified as a psychotropic medication.You are notified that: There may be available alternatives (other psychotropic medications) other than the one specifically prescribed. Along with all medications, psychotropic medications are reviewed quarterly by the interdisciplinary team and the physician. The benefits, risks, adverse consequences, and side effects have been discussed. Consent can be withdrawn at any time by written notification. Potential side effects have been discussed and are being monitored. Questions about the medications can be answered by the nursing staff. You have the right to refuse treatment at any time.By signing below, you agree that you have read and understood.Further review revealed this document was signed on 12/6/2025 by the resident's representative. Additionally, this document failed to identify any of the psychotropic medications the resident is prescribed. Further record review failed to reveal evidence the resident and/or residents representative were informed, in advance, of the addition of new psychotropic medications to the resident's medication regimen or dosage increases to pre-existing psychotropic medications prior to initiating therapy, for the above psychotropic medications. Additionally, record review failed to reveal evidence that the resident and/or resident's representative was informed of the risks and benefits, side effects, and/or treatment alternatives.C. Record review revealed Resident ID #4 was readmitted to the facility in February of 2026 with diagnoses including, but not limited to, anxiety disorder and major depressive disorder.Review of a care plan focus area for psychotropic medication use, last revised 6/22/2026, revealed the resident receives a psychotropic medication and is at risk for side effects, adverse drug reactions, and oversedation.Record review revealed the resident was prescribed and subsequently was administered the following psychotropic medication:-3/4/2026: Duloxetine capsule, delayed release, 30 mg, with instructions to administer 90 mg once daily.Record review failed to reveal evidence the resident and/or representative were informed, in advance, of the addition of a new psychotropic medication to the resident's medication regimen or dosage increases to pre-existing psychotropic medications prior to initiating therapy, for the above psychotropic medication. Additionally, record review failed to reveal evidence that the resident and/or resident's representative was informed of the risks and benefits, side effects, and/or treatment alternatives.D. Record review revealed Resident ID #5 was admitted to the facility in August of 2024 with a diagnosis including, but not limited to, Alzheimer's disease.Review of a care plan focus area for psychotropic medication use, last revised on 5/7/2026, revealed the resident receives psychotropic medications for the treatment of sundowning/mood/agitation and is at risk for side effects, adverse drug reactions, and oversedation.Record review revealed the resident was prescribed and was subsequently administered the following psychotropic medications:-3/31/2026-4/1/2026: Ativan 0.5 mg with instructions to administer 0.25 mg every four hours as needed-4/1/2026-4/1/2026: Ativan 0.5 mg with instructions to administer 0.25 mg three times a day-4/2/2026-4/24/2026: Ativan 0.5 mg with instructions to administer 0.25 mg three times a day-4/24/2026: Ativan 0.5 mg with instructions to administer 0.5 mg three times a dayRecord review revealed a document titled, ALPINE PSYCHOTROPIC MEDICATION CONSENT FOR USE AND TREATMENT, dated 3/6/2025, states in part, .At admission and at any time after that the prescribing physician or nurse practitioner may order a medication that is classified as a psychotropic medication.You are notified that: There may be available alternatives (other psychotropic medications) other than the one specifically prescribed. Along with all medications, psychotropic medications are reviewed quarterly by the interdisciplinary team and the physician. The benefits, risks, adverse consequences, and side effects have been discussed. Consent can be withdrawn at any time by written notification. Potential side effects have been discussed and are being monitored. Questions about the medications can be answered by the nursing staff. You have the right to refuse treatment at any time.By signing below, you agree that you have read and understood.Further review revealed this document was signed on 7/29/2025 by the resident's representative. Additionally, this document failed to identify any of the psychotropic medications the resident is prescribed. Record review failed to reveal evidence the resident and/or representative were informed, in advance, of the addition of new psychotropic medications to the resident's medication regimen or dosage increases to pre-existing psychotropic medications prior to initiating therapy, for the above psychotropic medications. Additionally, record review failed to reveal evidence that the resident and/or resident's representative was informed of the risks and benefits, side effects, and/or treatment alternatives.E. Record review revealed Resident ID #28 was admitted to the facility in August of 2024 with a diagnosis including, but not limited to, Alzheimer's disease with late onset.Review of a care plan focus area for psychotropic medication use, last revised on 6/1/2026, revealed the resident receives antidepressant medications.Record review revealed the resident was prescribed and was subsequently administered the following psychotropic medications:-3/7/2026: Trazodone 50 mg with instructions to administer 25 mg twice daily-6/6/2026: Sertraline 100 mg with instructions to administer once daily at bedtimeRecord review failed to reveal evidence the resident and/or representative were informed, in advance, of the addition of new psychotropic medications to the resident's medication regimen or dosage increases to pre-existing psychotropic medications prior to initiating therapy, for the above psychotropic medications. Additionally, record review failed to reveal evidence that the resident and/or resident's representative was informed of the risks and benefits, side effects, and/or treatment alternatives.F. Record review revealed Resident ID #30 was readmitted to the facility in September of 2025 with a diagnosis including, but not limited to, Parkinson's disease.Review of a care plan focus area for psychotropic medication use, last revised on 6/22/2026, revealed the resident receives psychotropic medications and is at risk for side effects, adverse drug reactions, and oversedation.Record review revealed the resident was prescribed and subsequently administered the following psychotropic medications:-1/22/2026: Seroquel 50 mg with instructions to administer twice daily-1/31/2026: Trazodone 50 mg with instructions to administer 25 mg once daily, after breakfast-1/31/2026: Trazodone 50 mg with instructions to administer once daily, after lunch-1/31/2026-2/13/2026: Trazodone 50 mg with instructions to administer twice daily as needed-3/18/2026-5/18/2026: Trazodone 50 mg with instructions to administer 25 mg twice daily as needed-5/30/2026-8/30/2026: Trazodone 50 mg with instructions to administer 25 mg twice daily as needed-6/18/2026-7/18/2026: Lorazepam 2 mg/milliliter (ml) with instructions to administer 0.5 mg/0.25 ml, every four hoursRecord review failed to reveal evidence the resident and/or representative were informed, in advance, of the addition of new psychotropic medications to the resident's medication regimen or dosage increases to pre-existing psychotropic medications prior to initiating therapy, for the above psychotropic medications. Additionally, record review failed to reveal evidence that the resident and/or resident's representative was informed of the risks and benefits, side effects, and/or treatment alternatives.During a surveyor interview on 7/10/2026 at 12:23 PM, with Charge Nurse, Licensed Practical Nurse, Staff A, she revealed that psychotropic consent is obtained upon admission and a consent form is signed by the resident and/or resident's representative. She revealed the facility obtains consent verbally with every medication change but was unable to provide evidence of psychotropic consents for Resident ID #s 1, 3, 4, 5, 28, and 30, for all the above psychotropic medications.During a surveyor interview on 7/13/2026 at 12:00 PM, with the Director of Nursing Services, she revealed that psychotropic consent is only obtained upon admission. Further, she was unable to provide evidence that Resident ID #s 1, 3, 4, 5, 28, and 30 and/or their representatives were informed, in advance, of the addition of a new psychotropic medication to the resident's medication regimen or that dosage increases to pre-existing psychotropic medications, the risks and benefits, side effects, and/or treatment alternatives, prior to initiating psychotropic medication therapy.

Based on clinical record review and staff interview, the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic for 5 of 5 residents reviewed for antibiotic use, Resident ID #s 6, 19, 29, 42 and 44. Findings are as follows:According to the Centers for Disease Control and Prevention document titled, The Core Elements of Antibiotic Stewardship for Nursing Homes states in part, Standardize the practices which should be applied during the care of any resident suspected of an infection or started on an antibiotic. These practices include improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, optimizing the use of diagnostic testing, and implementing an antibiotic review process, also known as an antibiotic time-out, for all antibiotics prescribed in your facility. Antibiotic reviews provide clinicians with an opportunity to reassess the ongoing need for and choice of an antibiotic when the clinical picture is clearer and more information is available .Track the amount of antibiotic used in your nursing home to review patterns of use and determine the impact of new stewardship interventions .Interventions designed to shorten the duration of antibiotic courses, or discontinue antibiotics based on post-prescription review (i.e., antibiotic time-out), may not necessarily change the rate of antibiotic starts, but would decrease the antibiotic DOT [days of therapy] .Record review of a facility policy titled Antibiotic Stewardship states in part, .To maintain an ongoing Antibiotic Stewardship Program (ASP) that promotes the appropriate use of antibiotics in the treatment of resident infections.Antibiotic time out 48-72 hours post initiation to consider the following.colonization [a condition where microorganisms are present in a host without causing disease] vs [versus] infection positive resident response possible early discontinuation.1. Record review revealed that Resident ID #6 was admitted to the facility in October of 2021 with diagnoses including, but not limited to, diabetes and dementia.Record review revealed a physician's order for levofloxacin (an antibiotic) 500 milligram (mg) daily from 6/29/2026 through 7/5/2026 for pneumonia.Record review failed to reveal evidence that the facility implemented an antibiotic review process, also known as an antibiotic time-out, to determine if the antibiotic is still indicated or adjustments should be made.2. Record review revealed that Resident ID #19 was admitted to the facility in October of 2016 with a diagnosis including, but not limited to, hypertension (high blood pressure).Record review revealed a physician's order for doxycycline hyclate (an antibiotic) 100 mg tablet twice a day from 6/25/2026 through 7/1/2026 for pneumonia.Record review failed to reveal evidence that the facility implemented an antibiotic review process, to determine if the antibiotic is still indicated or adjustments should be made.3. Record review revealed that Resident ID #29 was admitted to the facility in June of 2026 with a diagnosis including, but not limited to, pneumonia.Record review revealed a physician's order for levofloxacin 500 mg daily from 7/2/2026 through 7/8/2026 for pneumonia.Record review failed to reveal evidence that the facility implemented an antibiotic review process, to determine if the antibiotic is still indicated or adjustments should be made.4. Record review revealed that Resident ID #42 was admitted to the facility in January of 2026 with a diagnosis including, but not limited to, chronic diastolic heart failure (a condition that occurs when the left side of the heart becomes stiff and cannot fill properly with blood).Record review revealed a physician's order for Augmentin (an antibiotic) 500/125 mg daily from 7/7/2026 through 7/12/2026 for a surgical site infection and pneumonia.Record review failed to reveal evidence that the facility implemented an antibiotic review process, to determine if the antibiotic is still indicated or adjustments should be made.5. Record review revealed that Resident ID #44 was admitted to the facility in August of 2025 with diagnoses including, but not limited to, pneumonia and chronic cough.Record review revealed a physician's order for clindamycin (an antibiotic) 300 mg daily from 7/9/2026 through 7/18/2026 for pneumonia.Record review failed to reveal evidence that the facility implemented an antibiotic review process, to determine if the antibiotic is still indicated or adjustments should be made.During a surveyor interview on 7/10/2026 at 9:39 AM, with the Director of Nursing Services, she was unable to provide evidence that the facility completed the antibiotic time outs for Resident ID #s 6, 19, 29, 42 and 44.

Based on clinical record review and staff interview, the facility failed to ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the long term care facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, relative to 3 of 3 residents reviewed who receive hospice services, Resident ID #s 2, 6, and 30.Findings are as follows:1. Record review revealed Resident ID #2 was admitted to the facility in May of 2026 with diagnoses including, but not limited to, follicular lymphoma (a type of blood cancer) and adult failure to thrive.Record review revealed that the resident was admitted to hospice on 6/24/2026.Additional record review of the resident's electronic and paper medical record failed to reveal evidence of a signed hospice election form or the resident's hospice certification and plan of care.2. Record review revealed Resident ID #6 was re-admitted to the facility in January of 2026 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (a progressive lung condition which restricts airflow and makes breathing difficult) and adult failure to thrive.Record review revealed that the resident was admitted to hospice on 1/23/2026.Additional record review of the resident's electronic and paper medical record failed to reveal evidence of the resident's hospice certification and most recent plan of care.3. Record review revealed Resident ID #30 was admitted to the facility in September of 2025 with a diagnosis including, but not limited to, Parkinson's disease.Record review revealed that the resident was admitted to hospice on 6/18/2026.Additional record review of the resident's electronic and paper medical record failed to reveal evidence of the resident's hospice certification and most recent plan of care.During surveyor interviews with Charge Nurse, Staff A, on 7/13/2026 at 9:11 AM, 10:35 AM, and 11:02 AM, she revealed that all hospice documents should be scanned into the resident's electronic medical record and acknowledged they were not. During a surveyor interview with the Director of Nursing Services on 7/13/2026 at 11:23 AM, she revealed that the residents' hospice certification and plans of care are sent to her email. However, she acknowledged that she had not uploaded them into the residents' electronic medical record until it was brought to her attention by the surveyor.

Based on clinical record review and staff interview, the facility failed to complete a Significant Change in Status Assessment (SCSA) within 14 days after there had been a significant change in the resident's physical or mental condition, for 2 of 3 residents reviewed for hospice services, Resident ID #s 2 and 30.Findings are as follows:According to the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, Version 1.20.1, last revised October 2025, page 46, states in part, .An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD [Assessment Reference Date] must be within 14 days from the effective date of the hospice election.Review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, last revised 7/23/2025, page 236, states in part, .A Significant Change in Status MDS [Minimum Data Set] is required when.A resident enrolls in a hospice program.A Significant Change in Status MDS is considered timely when: The RN [Registered Nurse] Assessment Coordinator signs the MDS as complete at section Z0500B [and] V0200B2 by the 14th calendar day after the determination that a significant change has occurred (determination date [plus] 14 calendar days).A. Record review revealed Resident ID #2 was admitted to the facility in May of 2026 with a diagnosis including, but not limited to, Follicular lymphoma (a blood cancer). Further review revealed the resident was admitted to hospice services on 6/24/2026.Record review revealed an SCSA with an ARD date of 7/7/2026. Further review revealed that as of 7/13/2026, the SCSA was listed as in progress. Additionally, Section Z titled, Assessment Administration failed to reveal a RN Assessment Coordinator signature and date, indicating the SCSA is still incomplete, 19 days after a significant change in status was determined, due to the resident being admitted to hospice services.B. Record review revealed Resident ID #30 was readmitted to the facility in September of 2025 with a diagnosis including, but not limited to, Parkinson's disease. Further review revealed the resident was admitted to hospice services on 6/18/2026.Record review revealed an SCSA with an ARD date of 7/2/2026. Further review revealed that as of 7/13/2026, the SCSA was listed as in progress. Additionally, Section Z titled, Assessment Administration failed to reveal a RN Assessment Coordinator signature and date, indicating the SCSA is still incomplete, 25 days after a significant change in status was determined, due to the resident being admitted to hospice services.During a surveyor interview on 7/13/2026 at 10:40 AM, with the Resident Assessment Coordinator, she acknowledged that the SCSA for Resident ID #s 2 and 30 were still in progress and were not completed.During surveyor interviews on 7/13/2026 at 11:10 AM and 11:23 AM, with the Director of Nursing Services, she revealed that the date of hospice admission is considered the date of the significant change in status and revealed that she would expect the SCSAs to be completed in the required time frame.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 3 residents reviewed for oxygen therapy, Resident ID #33.Findings are as follows:Record review revealed the resident was readmitted to the facility in January of 2026 with a diagnosis including, but not limited to, atrial fibrillation (an irregular heart rhythm which can cause symptoms such as heart palpitations, and shortness of breath).Record review revealed a physician's order dated 12/18/2025 for oxygen at 2-4 liters per minute (LPM) via nasal cannula for shortness of breath every shift, as needed.During surveyor observations the resident was noted to be receiving oxygen outside of the ordered LPM, on the following dates and times:7/8/2026 at 12:57 PM- oxygen at 1.5 LPM7/9/2026 at 8:25 AM- oxygen at 1 LPM7/9/2026 at 3:26 PM- oxygen at 1 LPMDuring a surveyor observation and simultaneous interview on 7/9/2026 at approximately 3:28 PM, in the presence of Registered Nurse, Staff B, she acknowledged that the resident's oxygen was being administered at 1 LPM. She further acknowledged that this dosage did not fall into the range ordered by the physician.Review of the July 2026 Medication Administration Record revealed documentation that the resident had been receiving oxygen at 1.5 LPM, which was outside of the range ordered by the physician, on the following dates and times:7/1/2026 on the 3:00 PM - 11:00 PM and 11:00 PM - 7:00 AM shifts7/2/2026 on the 7:00 AM - 3:00 PM, 3:00 PM - 11:00 PM, and 11:00 PM- 7:00 AM shifts7/3/2026 on the 7:00 AM - 3:00 PM, 3:00 PM - 11:00 PM, and 11:00 PM- 7:00 AM shifts7/4/2026 on the 7:00 AM - 3:00 PM, 3:00 PM - 11:00 PM, and 11:00 PM- 7:00 AM shifts7/5/2026 on the 7:00 AM - 3:00 PM, 3:00 PM - 11:00 PM, and 11:00 PM- 7:00 AM shifts7/6/2026 on the 7:00 AM - 3:00 PM, 3:00 PM - 11:00 PM, and 11:00 PM- 7:00 AM shifts7/7/2026 on the 7:00 AM - 3:00 PM, 3:00 PM - 11:00 PM, and 11:00 PM- 7:00 AM shifts7/8/2026 on the 7:00 AM - 3:00 PM, 3:00 PM - 11:00 PM, and 11:00 PM- 7:00 AM shifts7/9/2026 on the 7:00 AM - 3:00 PM and 3:00 PM - 11:00 PM shiftsDuring a surveyor interview on 7/9/2026 at 3:36 PM, with the Director of Nursing Services, she revealed that she would expect the amount of oxygen that was administered to the resident to match the physician's order.

Based on clinical record review and staff interview, the facility failed to conduct a comprehensive assessment of a resident within 14 calendar days after admission, excluding readmission in which there is no significant change in the resident's physical or mental condition, relative to 2 of 3 residents reviewed for readmission after hospitalization, Resident ID #s 6 and 29.Findings are as follows:1. Record review revealed Resident ID #6 was re-admitted to the facility in January of 2026 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (a progressive lung condition that restricts airflow and makes breathing difficult) and adult failure to thrive.Record review revealed s/he was admitted to hospice on 1/23/2026.Record review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed, the assessment was not completed until 2/8/2026, 18 days after his/her admission to the facility.2. Record review revealed Resident ID #29 was re-admitted to the facility in June of 2026 with diagnoses including, but not limited to, pneumonia.Record review revealed s/he was discharged from the facility on 6/25/2026 and was readmitted on [DATE].Record review of a Discharge MDS assessment dated [DATE] revealed, the assessment was incomplete as of 7/13/2026, 18 days after his/her discharge from the facility.During surveyor interviews with the Resident Assessment Coordinator on 7/13/2026 at 8:52 AM and 10:49 AM, she acknowledged that the above MDS assessments were not completed and submitted within the required timeframes.During a surveyor interview with the Director of Nursing Services on 7/13/2026 at 11:10 AM, she revealed she would expect the above-mentioned MDS Assessments to be completed within the required timeframes.

Based on record review and staff interview, the facility failed to provide prorated interest for residents whom the facility is holding personal funds in a single interest-bearing account relative to 2 of 4 residents reviewed, Resident ID #s 15 and 46. Findings are as follows:According to the Centers for Medicare & Medicaid Services (CMS), specifically under 42 CFR S 483.10(f)(10), facilities must manage a resident's funds in a system that holds them separate from the facility's operational funds. When these funds are pooled in a single interest-bearing account, the interest must be prorated individually based on actual earnings or end of quarter balance.1. Record review revealed Resident ID #15 was admitted to the facility in August of 2019.Record review of a document titled Personal Needs Statement failed to reveal evidence that Resident ID #15 received prorated interest from 3/31/2025 through 2/28/2026.2. Record review revealed Resident ID #46 was admitted to the facility in April of 2018.Record review of a document titled, Personal Needs Statement failed to reveal evidence that Resident ID #46 received prorated interest from 8/31/2025 through 2/28/2026.During a surveyor interview on 7/13/2026 at approximately 1:06 PM with the Administrator, he was unable to provide evidence that Resident ID #s 15 and 46 received prorated interest.

Based on record review and staff interview, it has been determined that the facility failed to provide a dietary menu that meets the nutritional needs of residents in accordance with established national guidelines. Findings are as follows: Record review of the facility's diet manual titled, Alpine Nursing Home LLC Dietary Manual 2024-2025 failed to have the established national guidelines included in the diet manual for the development of the regular menu as well as for therapeutic diet offerings. Additionally, the manual failed to have the current Dietary Reference Intakes (a set of scientifically developed reference values for nutrients that refer to the average daily nutrient intake of a population) to ensure the nutritional adequacy of the menu served to their resident population. Record review of a document published by the United States Department of Agriculture (USDA), revealed that a standardized recipe is utilized in a food service establishment to ensure the nutritional values per serving are valid and consistent, as the same products and quantities are being used every time the recipe is produced. Record review of the menu served from 3/24/2025 through 3/27/2025 failed to reveal evidence standardized recipes were on file. During a surveyor interview on 3/24/2025 at 11:24 AM with the Food Service Director, in the presence of the Director of Nursing Services, he revealed that the facility does not have standardized recipes with caloric and nutrient content.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety relative to the main kitchen. Findings are as follows: 1. Record review of the State Operations Manual Appendix PP-Guidance to Surveyors for Long term Care Facilities 483.60(i)(1)-(2) states in part, chemical products and supplies, must be clearly marked . Record review of the Occupational Safety and Health Administration Standard 1910.1200 (f)(1) states in part, .chemicals are marked with a product identifier, signal word (danger or warning), a statement that the full label information for the chemical is provided on the outside package . During a surveyor observation on 3/24/2025 at approximately 8:45 AM, upon entrance to the main kitchen, the following was observed: - one spray bottle with the words isopropyl alcohol handwritten in black magic marker. An additional surveyor observation on 3/26/2025 at 10:50 AM, upon entrance to the main kitchen, in the presence of the Food Service Director (FSD), the following was observed: - one spray bottle with the words isopropyl alcohol handwritten with a black magic marker. - two spray bottles with the words orange sanitizer that was handwritten in black magic marker. The observed spray bottles failed to have a label that included a signal word or a statement that the full label information for the chemical was provided on the outside package. 2. Record review of the Rhode Island Food Code 2018 Edition 4-601-11 states in part, .Nonfood contact surfaces shall be kept free of an accumulation of dirt .and other debris . During a surveyor observation on 3/24/2025 at approximately 8:45 AM of the main kitchen, the rim of the hood over the stove was noted to have an accumulation of grease along the inner rim. An additional surveyor observation of the main kitchen on 3/26/2025 at 10:50 AM in the presence of the FSD, the rim of the hood over the stove was noted to have an accumulation of grease along the inner rim. During a surveyor interview immediately following the above observation with the FSD, he acknowledged that the rim of the hood needed to be cleaned. 3. The Rhode Island Food Code 2018 Edition 5-501.113 Covering Receptacles states in part,Receptacles .shall be kept covered .Contain food residue and are not in continuous use . During a surveyor observation of the main kitchen on 3/24/2025 at approximately 8:45 AM the following was observed: - one trash receptacle uncovered and not in continuous use, located adjacent to the pot and pan sink - one trash receptacle uncovered and not in continuous use in the dish room An additional surveyor observation of the main kitchen on 3/26/2025 at 10:50 AM, in the presence of the FSD, he acknowledged the trash receptacles were uncovered and not in continuous use. 4. The Rhode Island Food Code 2018 Edition 3-501.14 Cooling states in part, .cooked time/temperature control for safety food shall be cooled (1) within 2 hours from 57 degrees (135 degrees Fahrenheit [F]) to 21 degrees C (70 degrees F) . During a surveyor observation on 3/24/2025 at 3:00 PM, the split pea soup was in an ice bath cooling down. Record review of a cooling log states in part, .1:00PM split peas soup 135 degrees F . During a surveyor observation, in the presence of the FSD on 3/24/2025 at 3:00 PM, an internal temperature was taken of the split pea soup, and it had a reading of 86 degrees F. The FSD revealed that he was not aware that it did not meet the temperature reading at 2 hours, until it was brought to his attention by the surveyor.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who are trauma survivors receive trauma informed care in accordance with professional standards of practice and account for the resident's experiences and preferences for 5 of 15 residents reviewed for Trauma Informed Care, Resident ID #s 22, 26, 31, 50 and 51. Findings are as follows: Record review of State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, states in part, S483.25(m) Trauma-informed care .Assessment Facilities should use a multi-pronged approach to identifying a resident's history of trauma .This would include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), Admission Assessment, the history and physical, the social history/assessment, and others . Record review of a facility policy dated 7/25/2019 titled, Trauma-Informed Care & Compassion Fatigue, states in part, Trauma-Informed Care is a person-centered, culturally competent approach to care, which takes an individual's past traumatic experiences into account, recognizes the coping mechanisms that have resulted from the trauma and understands the behaviors that accompany the trauma; thereby, giving the individual a feeling of safety within his/her environment and a sense of well-being .as professional caregivers, we will encounter residents who have experienced trauma during their lives .we must have the ability to impact these individuals in a positive way through person-centered care . 1. Record review revealed Resident ID #31 was admitted to the facility in August of 2020 with diagnoses including, but not limited to, depression, anxiety and dementia with psychotic disturbance (a diagnosis that affects the mind and makes it harder for someone to think clearly, make good judgments, respond emotionally and communicate effectively). Review of a social service quarterly assessment note dated 11/3/2023, revealed the resident's Power of Attorney disclosed to the social worker that the resident's past includes a history of trauma and also revealed that Resident ID #31 witnessed his/her spouse endure a tragic accident involving a fall, which resulted in his/her death. Record review of the psychiatric assessment notes dated 1/19/2024 and 2/16/2024, states in part, .though memory often seems reasonable .impresses me as having a H/O (history of) being traumatized but will not answer questions about past . Further record review failed to reveal evidence that an assessment for trauma was completed or that a care plan for trauma was developed or implemented for Resident ID #31. 2a. Record review for Resident ID #22 revealed the resident was admitted to the facility in June of 2023 with a diagnosis including, but not limited to, vascular dementia. 2b. Record review for Resident ID #26 revealed the resident was admitted to the facility in June of 2023 with a diagnosis including, but not limited to, dementia. 2c. Record review for Resident ID #50 revealed the resident was admitted to the facility in August of 2023 with diagnoses including, but not limited to, Alzheimer's disease and anxiety. 2d. Record review for Resident ID #51 revealed the resident was admitted to the facility in September of 2023 with diagnoses including, but not limited to, dementia and anxiety. Record review failed to reveal evidence that trauma informed care assessments were completed for the above-mentioned residents. During a surveyor interview with the Director of Nursing Services on 4/15/2024 at 11:48 AM and again at 11:50 AM, she revealed that the Trauma assessments are to be completed by the Social Worker. Additionally, she was unable to provide evidence that the above mentioned residents had trauma informed care assessments completed. 47939 49184

Based on surveyor observation, record review and staff interview it has been determined that the facility failed to ensure nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being of each resident, as determined by resident assessments and individual plans of care, for 5 of 5 Medication Technicians (MTs) reviewed relative to obtaining an apical pulse (AP- a heartbeat measurement by listening with a stethoscope to the left center of the chest. This is the most accurate evaluation of a person's heart rate, particularly when pulse an abnormality is detected) for Staff A, D, E, F, and G. Findings are as follows: According to the State Operation Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023 which states in part, .To assure that all nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being .'Competency' is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully . Record review revealed Resident ID #8 was admitted to the facility in December of 2022 with a diagnosis including, but not limited to, bradycardia (a slow heart rate which can occur due to heart issues and other health conditions). Further record review revealed the resident has a physician's order dated 1/5/2024 and revised on 4/12/2024 for .Monitor ./AP daily. Pending cardiology follow up appointment for medication management . During a surveyor observation of MT, Staff A on 4/12/2024 at 9:30 AM revealed she obtained the resident's radial pulse (a pulse that can be felt/measured at the radial artery, which is located on the thumb side of the wrist) instead of the apical pulse as ordered. During a surveyor interview, following the above observation with Staff A on 4/12/2024 at 9:47 AM, she acknowledged she obtained the radial pulse instead of the apical pulse. Staff A further revealed she has been obtaining a radial pulse and documenting it on the Medication Administration Record (MAR) as if she was obtaining an apical pulse. During a surveyor interview with the Director of Nursing Services (DNS) on 4/12/2024 at 10:00 AM, she acknowledged that Staff A obtained a radial pulse instead of an apical pulse. The DNS further revealed that there are 5 Medication Technicians (Staff A, D, E, F, and G) that work in the facility and she was unable to provide evidence that these Medication Technicians had demonstrated the competencies and skill sets for obtaining an apical pulse. 47939

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to following a physician's order for 1 of 1 resident reviewed for apical pulse (AP- a heartbeat measurement by listening with a stethoscope to the left center of the chest. This is the most accurate evaluation of a person's heart rate, particularly when an abnormality is detected), Resident ID #8. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review revealed the resident was admitted to the facility in December of 2022 with diagnosis including, but not limited to, bradycardia (a slow heart rate that can occur due to heart issues and other health conditions). Further record review revealed the resident has a physician's order dated 1/5/2024 and revised on 4/12/2024 for .Monitor ./AP daily. Pending cardiology follow up appointment for medication management . During a surveyor observation of Medication Technician, Staff A, on 4/12/2024 at 9:30 AM revealed she obtained the resident's radial pulse (pulse that can be felt/measured at the radial artery, which is located on the thumb side of the wrist) instead of the apical pulse as ordered. During a surveyor interview, following the above observation with Staff A on 4/12/2024 at 9:47 AM, she acknowledged she obtained the radial pulse instead of the apical pulse. Staff A further revealed she has been obtaining a radial pulse and documenting it on the Medication Administration Record (MAR) as if she was obtaining as apical pulse. Record review of the MAR for April 2024 revealed Staff A documented that she obtained the apical pulse on 8 out of 12 days -4/1/2024 -4/3/2024 -4/4/2024 -4/5/2024 -4/8/2024 -4/9/2024 -4/10/2024 -4/12/2024 During a surveyor interview with the Director of Nursing Services on 4/12/2024 at 10:00 AM, she acknowledged that Staff A obtained the radial pulse instead of the apical pulse and further indicated that it is her expectation that staff would follow the physician's order. 47939

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 2 of 2 residents reviewed for respiratory care, Resident ID #s 2 and 23. Findings are as follows: Record review of a facility policy undated and titled, Use of Oxygen, Nebulizers [medical device that turns liquid medication into a very fine mist that a person can inhale through a face mask or mouthpiece] & Supplies, states in part, .1. All nasal cannulas [a device used to deliver supplemental oxygen or increased airflow to a patient], masks, and humidifier bottles will be changed, labeled, and signed off on the emar [electronic medication administration record] once a week 2. Extension tubing and connectors will be changed once a week, labeled, and signed on emar . 1. Record review revealed Resident ID #2 was readmitted to the facility in May of 2023 with diagnoses including, but not limited to, acute and chronic respiratory failure with hypercapnia (an elevated level of carbon dioxide in the blood), obstructive sleep apnea (obstruction of the upper airway during sleep), and pulmonary fibrosis (a lung disease that occurs when lung tissue becomes damaged and scarred). Review of a physician's order dated 7/29/2023, revealed change oxygen tubing every week on Saturdays, on 11-7 [11:00 PM to 7:00 AM]. Review of the April 2024 Treatment Administration Records (TAR) revealed the nurse had signed off the physician's order that she changed the resident's oxygen tubing on 4/6/2024. During multiple surveyor observations on 4/10/2024 and 4/11/2024 revealed the resident was noted to have oxygen tubing labeled with a date of 3/31. During a surveyor interview with Licensed Practical Nurse, Staff B on 4/11/2024 at 12:30 PM while in the resident's room, she acknowledged the resident's oxygen tubing was dated 3/31. During a surveyor interview with the Director of Nursing Services (DNS) on 4/11/2024 at 12:40 PM immediately following the above observation and while in the presence of Staff B, she stated she would have expected the resident's oxygen tubing to be changed per the physician's order. 2. Record review revealed Resident ID #23 was admitted to the facility in January of 2022 with diagnoses including, but not limited to, chronic obstructive pulmonary disease [a chronic inflammatory lung disease that causes obstructed airflow from the lungs] and heart failure. Review of a physician's order dated 10/6/2023, revealed o2 [oxygen] 2-4 liters per min via nasal cannula prn [as needed] for SOB [shortness of breath]. During surveyor observations of the resident on 4/11/2024 at 2:50 PM and 4/12/2024 at 9:50 AM revealed oxygen was in place via nasal cannula and the liter flow was set at 1.5 liters per minute. During a surveyor interview with Registered Nurse, Staff C, on 4/12/2024 immediately following the above observation, she acknowledged the resident is receiving 1.5 liters per minute of oxygen when the physician's order is for the resident to received 2-4 liters per minute. During a surveyor interview with the DNS on 4/15/2024 at 10:29 AM she revealed that her expectation would be for the physician's order to be followed. 47939

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and practices for 2 of 2 residents reviewed relative to oxygen therapy, Resident ID #s 2 and 23. Findings are as follows: 1. Record review for Resident ID #2 revealed s/he was admitted to the facility in May of 2023 with diagnoses including, but not limited to, acute and chronic respiratory failure with hypercapnia (an elevated level of carbon dioxide in the blood), obstructive sleep apnea (obstruction of the upper airway during sleep) and pulmonary fibrosis (a lung disease that occurs when lung tissue becomes damaged and scarred). Record review revealed a physician's order dated 7/29/2023 to change oxygen the tubing every week on Saturdays, during the 11:00 PM to 7:00 AM shift. Record review of the April 2024 Treatment Administration Record (TAR) revealed the nurse had signed off the physician's order that she changed the resident's oxygen tubing on 4/6/2024. During multiple surveyor observations on 4/10/2024 and 4/11/2024 the resident was observed to be receiving oxygen via nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient), and the oxygen tubing was dated 3/31. During a surveyor observation and simultaneous interview with Licensed Practical Nurse, Staff B on 4/11/2024 at 12:30 PM, she acknowledged the date of 3/31 on the resident's oxygen tubing. During a surveyor interview with the Director of Nursing Services on 4/11/2024 at 12:40 PM, she was unable to explain why the nursing staff had inaccurately documented in the resident's record that they had changed the resident's oxygen tubing on 4/6/2024, when they did not. 2. Record review revealed Resident ID #23 was admitted to the facility in January of 2022 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and heart failure. Review of a physician's order dated 10/6/2023, revealed o2 [oxygen] 2-4 liters per min [minute] via nasal cannula prn [as needed] for SOB [shortness of breath]. During surveyor observations of the resident on 4/11/2024 at 2:50 PM and 4/12/2024 at 9:50 AM revealed the oxygen was in place via nasal cannula. Record review of the April 2024 TAR revealed that the PRN oxygen order was not signed of as being administered on 4/11/2024 and 4/12/2024. During a surveyor interview with Registered Nurse, Staff C, on 4/12/2024 immediately following the above observation, she acknowledged that she did not sign the TAR for the oxygen being administered to Resident ID #23 on 4/12/2024. During a surveyor interview with the DNS on 4/15/2024 at 10:29 AM she revealed that her expectation is that nursing staff document when PRN oxygen is administered on the TAR. 47808 37158

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to conduct appropriate infection control practices relative to personal protective equipment (PPE) and hand hygiene for 2 of 2 staff members, Staff D and E, observed during care of COVID-19 positive residents, Resident ID #s 40 and 41. Findings are as follows: Record review of an undated facility policy titled, Alpine Nursing Home Infection Prevention and Control Program states in part, .Transmission Based Precautions .B. Droplet precautions personal protective equipment (PPE) will be used upon entering the room of a resident on respiratory droplet precautions .Contact Precautions-Personal Protective Equipment (PPE) will be used upon entering the room to prevent clothing of caregivers or visitors form contact with the infected resident, environmental surfaces or items in the room . During the entrance conference with the Director of Nursing Services (DNS) on 4/10/2024 at 10:04 AM she revealed that the facility was experiencing a COVID-19 outbreak for a total of 12 residents, including Resident ID #s 40 and 41. She indicated that these residents are on droplet and contact precautions. 1. Record review revealed Resident ID #40 was admitted to the facility in April of 2022 with a diagnosis including, but not limited to, Alzheimer's disease. During a surveyor observation on 4/11/2024 at 12:55 PM revealed, an ungloved hand reaching out of Resident ID #40's room to remove a spoon from the medication cart in the hallway. Further observation revealed Medication Technician (MT), Staff D, administering eye drops to Resident ID #40 without wearing gloves. Additionally, she proceeded to touch the resident's bedside table and open his/her side table drawer without wearing gloves or performing hand hygiene. During a surveyor interview immediately following the above observation with Staff D on 4/11/2024, she acknowledged that she did not apply gloves prior to entering a COVID-19 positive room that required droplet and contact precautions. She indicated that she should have performed hand hygiene and donned (put on) gloves prior to administering the resident's eye drops. 2. Record review revealed Resident ID #41 was admitted to the facility in January of 2022 with a diagnosis including, but not limited to, type 2 diabetes (high blood sugar level). During a surveyor observation on 4/11/2024 at 1:41 PM revealed, Nursing Assistant, Staff E, was performing nail care for the resident in his/her room without wearing gloves. Additionally, she was observed brushing the nail clippings off the resident's bed onto the floor. She also touched the resident's bedside table without wearing gloves. During a surveyor interview immediately following the above observation with Staff E, she acknowledged that she did not apply gloves prior to entering a COVID-19 positive room that required droplet and contact precautions. During a surveyor interview with the DNS on 4/15/2024 at 10:23 AM, she revealed that she would expect staff to follow proper infection control practices. Additionally, she was unable to explain why Staff D and E did not don appropriate PPE when they entered COVID-19 positive resident rooms.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that the assessment accurately reflected the resident's status for 1 of 1 resident reviewed for hand contractures (shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff), Resident ID #23. Findings are as follows: Record review revealed the resident was admitted to the facility in January of 2022 with diagnoses including, but not limited to, age-related physical disability, tremors, and contracture of the right hand. Record review of an Occupation Therapy (OT) evaluation plan and treatment dated 4/10/2023 through 5/9/2023 revealed the resident was evaluated and treated for a contractures to his/her left-hand. Additional record review revealed s/he experienced a functional limitation due to this contracture. Record review of an OT evaluation plan and treatment dated 10/24/2023 through 11/22/2023 revealed the resident was evaluated and treated for contractures to his/her left and right hands. Additional review revealed s/he experienced functional limitations due to these contractures. During a surveyor observation of the resident on 4/10/2024 at approximately 9:00 AM revealed the resident's left and right hands appeared to be contracted. Record review of the Minimum Data Set (MDS) Assessments failed to reveal evidence of documentation the contractures to his/her upper extremities on the following dates after it was identified: -4/26/2023 -6/23/2023 -7/26/2023 -9/13/2023 -10/31/2023 -11/22/2023 -1/12/2024 (annual) -1/31/2024 -3/19/2024 During a surveyor interview with the Therapy Manager on 4/15/2024 at approximately 9:00 AM, she indicated that therapy had been working with the resident during the above-mentioned dates related to his/her hand contractures. Additionally, she revealed that hand contractures, the limited range of motion and muscle shortness contributed to the resident overall decline in activities of daily living due to the inability to use his/her rolling walker. During a surveyor interview with the Director of Nursing Services on 4/15/2024 at 10:07 AM, she acknowledged the above mentioned MDS Assessments should have reflected the contractures to both of the resident's hands. Additionally, she was unable to provide evidence that the MDS assessments for Resident ID #23 were completed accurately, specific to his/her contractures.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that a resident's environment remains as free from accident hazards as possible for 1 of 3 residents reviewed for falls, Resident ID #6 relative to the facility failing to utilize a gait belt during a transfer. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 3/13/2023 revealed the resident fell while being transferred from a shower chair to a wheelchair and sustained a fracture of his/her right radial styloid process (wrist area). Review of the facility policy titled Policy for Safe Handling of Residents revealed .Any resident who is unable to rise unassisted from a seated position, should be transferred with a gait/transfer belt . Record review revealed that the resident was admitted to the facility in March of 2014 with diagnoses including, but not limited to, cerebrovascular disease (a condition that affects blood flow to the brain), lack of coordination, abnormalities of gait and mobility, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side (weakness on one side of the body following bleeding in the brain). Record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed s/he had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderately impaired cognition. Further review revealed the resident required extensive assistance and a two person physical assist for transfers. Additionally, the MDS revealed the resident required staff assistance when moving from a seated to a standing position. Record review of the care plan last edited 12/20/2022, revealed the resident had no movement in toes of right foot or ankle, loss of sensation on right lower leg . Further review revealed the resident .Requires extensive assistance with .transfers .2 person assist with all transfers with gait belt . Review of a physical therapy progress note dated 2/26/2023 revealed the resident required a 1 person assist with transfers. Record review of an occupational therapy progress note dated 3/1/2023 revealed the resident required Ext. A[extensive assistance] for all ADLS [activities of daily living] and transfers . Record review of a nursing note dated 3/10/2023 revealed the Resident slid in bathroom when being transferred from shower chair to wheelchair .fell into door .complaints of neck pain .resident to hospital for further evaluation . Review of the hospital documentation dated 3/10/2023 revealed the resident was diagnosed with a nondisplaced fracture of the right radial styloid process. During a surveyor observation on 3/15/2023 at approximately 11:30 AM, the resident was wearing a brace on his/her right wrist and had his/her arm elevated on a pillow. During a surveyor interview on 3/15/2023 at 11:51 AM with Nursing Assistant, Staff A, she revealed that on 3/10/2023 she attempted to transferred the resident from a shower chair into a wheelchair without a gait belt. She further revealed she wrapped her arms around the resident's waist and when they stood up, they both fell to the floor of the shower room. Additionally, she revealed this is how she typically transfers the resident. During a surveyor interview on 3/15/2023 at 12:00 PM with Charge Nurse, Staff B, she revealed that she would expect the resident to be transferred with a gait belt. During a surveyor interview on 3/15/2023 at 12:45 PM with Occupational Therapist, Staff C, she revealed that she would expect the staff to transfer the resident with the assistance of a gait belt. During a surveyor interview on 3/15/2023 at 1:13 PM with the Director of Nursing Services, she revealed that she would have expected the staff to transfer the resident with the assistance of a gait belt. 43376

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to properly store and prepare food in accordance with professional standards for food service safety relative to the main kitchen and nourishment room. Findings are as follows: Record review of the Rhode Island Food Code 2018 edition, section 4-602.11 states in part, . (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris . During a surveyor observation of the main kitchen on 3/16/2023 at 8:23 AM revealed the following: - Approximately 40 Imperial vanilla shakes in the reach in refrigerator, not dated. Manufacture's Instruction: Store frozen. Thaw under refrigeration. Use within 14 days. - Condenser fan in the walk- in refrigerator and freezer with an accumulation of debris. During a surveyor interview with the Food Service Director (FSD) on 3/16/2023 at 9:15 AM he acknowledged the condenser fan in the refrigerator and the freezer had a layer of accumulation of debris. Furthermore, he was unable to provide evidence of when the nutritional supplements were placed in the refrigerator and acknowledged they were not dated. During a surveyor observation of the kitchenette on 3/16/2023 at approximately 9:20 AM, in the presence of the FSD, he acknowledged there were 2 opened cartons of milk that were not dated and revealed that they should be discarded. During a surveyor observation of the lunch meal on 3/16/2023 at 12:12 PM revealed a food truck stationed at the nurses' station. The meal trays in the food truck contained uncovered desserts that was carried a distance to these resident rooms: - room [ROOM NUMBER], traveled approximately 30 feet (ft). - room [ROOM NUMBER] B, traveled approximately 30 ft. - room [ROOM NUMBER] A, traveled approximately 30 ft. - room [ROOM NUMBER], traveled approximately 40 ft. - room [ROOM NUMBER], traveled approximately 40 ft. - room [ROOM NUMBER], traveled approximately 30 ft. - room [ROOM NUMBER], traveled approximately 50 ft. During a surveyor interview with Nursing Assistant, Staff E, on 3/16/2023 at 12:27 PM, she acknowledged the pastry on the lunch trays were not covered. During a surveyor interview with the FSD on 3/16/2023 at 12:46 PM, he acknowledged that food traveling a distance should always be covered.

Based on record review and staff interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight for 1 of 6 residents reviewed who experienced an actual weight loss, Resident ID #12. Findings are as follows: Record review of a facility policy titled, Weighing residents: states in part, .All residents .weighed at least once a month .At any time, the nurse/MD [medical doctor] can ask for a resident to be weighed .Obtain reweighs as needed . Record review revealed the resident was admitted to the facility in November of 2018 with diagnoses including, but not limited to, Parkinson's disease (a chronic, progressive neurological disorder causing uncontrollable movements), dementia, and dysphagia (difficulty swallowing). Record review of a Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition is severely impaired. Further review of the MDS Assessment indicated the resident could eat independently and required only setup assistance from staff. Record review of a care plan problem category titled, Nutritional Status, edited 1/27/2023 states in part, .alteration in .nutritional status .Poor intake and refusing meals .has lost some weight. with interventions to monitor intake and report any issues, and weigh as ordered and report any fluctuations. Record review of the following progress notes indicated the resident had inadequate oral intake (consuming 25% or less of meals): - 3/5/2023 at 11:42 AM .refused breakfast . - 3/8/2023 at 2:33 PM .Refused breakfast and lunch . - 3/9/2023 at 9:52 PM .Poor PO [oral] intake . - 3/10/2023 at 11:04 PM .Very poor PO intake . - 3/13/2023 at 10:48 PM .Poor PO intake . Further record review of the resident's oral intake from 3/1/2023 through the breakfast meal on 3/17/2023 revealed the resident had either no documentation of a meal intake, refused his/her meal, or consumed 25% or less of his/her meal for 42 of 49 opportunities. Additional record review revealed the resident was offered a supplement for his/her inadequate meal intake for only 4 of the 42 opportunities. Record review of the resident's monthly weights from 1/21/2023 through 3/3/2023 revealed the following weights: - 1/21/2023: 166 pounds - 2/16/2023: 173 pounds - 3/1/2023: 186.2 pounds - 3/2/2023: 160.2 pounds - 3/3/2023: 158.6 pounds Record review of a document titled, WEIGHT LOSS 3/14 revealed the resident had a 33.4 pound weight loss from September 2022 through March 2023, indicating a 17.3% weight loss in 6 months. Additionally, the resident's weight was obtained at the surveyor's request on 3/17/2023 by Certified Nursing Assistant (CNA), Staff D, which revealed a current weight of 158.6 pounds. This indicated the resident had lost 14.4 pounds from 2/16/2023 through 3/17/2023, a severe weight loss of 8.3% in approximately 1 month. Record review revealed the resident was being assessed by the Dietitian on a monthly basis from September of 2022 through January of 2023. Further record review failed to reveal evidence that additional interventions were implemented following the recent weight loss and last nutritional assessment on 1/25/2023. During a surveyor interview on 3/17/2023 at 9:10 AM with the Charge Nurse, Staff B, she revealed weights are audited every Friday. She further revealed that a reweigh would be obtained for a significant weight gain or loss of 3 pounds in a day or 5 pounds in a week. During a follow up surveyor interview on 3/17/2023 at 10:02 AM with Staff B, she revealed for a resident that consumes 25% or less of his/her meal, the staff should offer a supplement. She further revealed she would expect to be informed by the staff if a resident had an inadequate meal intake. During a surveyor interview on 3/17/2023 at 10:43 AM with Staff D, she revealed the resident did not eat breakfast on 3/17/2023 and indicated she would inform the nurse, however she had been busy and did not inform the nurse that the resident did not eat breakfast that morning. Additionally, she revealed she should have offered the resident a supplement or meal alternative and document. Record review failed to reveal evidence any supplement or meal alternative had been offered to the resident until after it was brought to Staff D's attention by the surveyor. During a surveyor interview on 3/17/2023 at 1:38 PM with the Dietitian, she revealed she visits the facility weekly on Wednesdays. She further revealed that she is aware of the resident's continued weight loss and acknowledged the weight loss is severe. Additionally, she was unable to provide evidence that any other interventions were implemented since January for the resident's continued weight loss. During a surveyor interview on 3/17/2023 at 1:28 PM with the Director of Nursing Services, she revealed she would expect the staff to document the resident's meal intake and offer a supplement to a resident with a meal intake of 25% or less. Additionally, she revealed she expects the staff to inform the nurse if a resident is not eating well. She was unable to provide evidence that staff is consistently monitoring and documenting the resident's meal intake and offering supplements or alternatives as indicated to help residents maintain acceptable parameters of nutritional status.