Every finding on record at Cedar Haven Operations Holding LLC Valley View Hea

Based on surveyor observations, clinical record review, and resident and staff interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 3 of 4 units observed.Findings are as follows:Review of an undated facility policy titled Housekeeping and Maintenance Services states in part, Objective. To provide a safe, sanitary and clean environment for the residence in the facility .1. Review of a community report complaint submitted to the Rhode Island Department of Health on 6/15/2026, revealed Resident ID #39's family member saw a rat in the resident's room on 6/12/2026. Further review revealed staff were made aware of the sighting and stated that the facility is aware of the problem. Additionally, the complaint revealed that the resident is immobile and wouldn't be able to get away from the rodent if it crawled into the bed.Record review revealed Resident ID #39 was admitted to the facility in May of 2026 with diagnoses including, but not limited to, metabolic encephalopathy (a brain dysfunction) and chronic obstructive pulmonary disease.Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed a BIMS score of 6 out of 15, indicating severely impaired cognition. Further review revealed the resident is dependent on staff for activities of daily living and transfers.During a surveyor interview on 6/16/2026, at approximately 2:10 PM with Resident ID #39, s/he revealed that his/her family saw a mouse in his/her room recently and that mice were found in his/her roommate's bed. A surveyor observation on 6/8/2026 at 10:20 AM of the 3rd floor unit revealed a rodent walking under the baseboard heater of Resident ID #121's room.Review of the facility's service agreement with Allstate Pest Control signed on 3/4/2026, revealed the contracted service was for Bi-Weekly Rodent (Mice) Control.Review of the Rodent Monitoring Service Reports revealed that the pest control company set traps in the facility on 4/1/2026, 4/28/2026, and 5/15/2026. Further review failed to reveal evidence of bi-weekly rodent control, per the service agreement.During a surveyor interview on 6/15/2026 at 2:43 PM with the Administrator, she revealed that mice in the building was a concern recently discussed in the resident council meeting. She further revealed that bi-weekly rodent control was completed when the service agreement was originally signed, however, they decreased the visits to approximately every three weeks as they thought the rodent issue was improving.2. Surveyors' observations on all days of the survey, 3 of 4 units were observed with strong foul odors. These odors could be smelled from the hallways, inside resident rooms, and the bathrooms.Although all 7 surveyors observed foul odors throughout each day of the survey, facility staff members were willing to acknowledge their presence. 3. Record review revealed Resident ID #152 was admitted to the facility in November of 2024 with a diagnosis including, but not limited to, heart failure (when the heart muscle is too weak or stiff to pump enough oxygen-rich blood to meet the body's needs).Review of an MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderate cognitive impairment.During a surveyor interview on 6/8/2026 at 9:50 AM with the resident, s/he stated that his/her bed has not been made by the staff in three to four days and the staff does not wash the floor in his/her room. Additionally, the resident stated that his/her bedside table has been broken for months and has exposed sharp edges on the right corner of the table. Surveyor observation immediately following the above-mentioned interview revealed the bedside table was broken with exposed sharp edges. Additionally, the floor in the resident's room was sticky with noticeable discolored footprints. An additional surveyor observation on 6/9/2026 at 8:25 AM, of the resident's room, revealed the floor was still sticky, and the bedside table was in the same condition as observed on the previous day. During a simultaneous surveyor observation and interview of the above-mentioned resident's room on 6/10/2026 at 9:11 AM, in the presence of Nursing Assistant (NA), Staff A, she acknowledged the floor was sticky and the bedside table was broken.During a surveyor interview on 6/10/2026 at 9:17 AM with Licensed Practical Nurse, Staff B, she stated that she was not aware the bedside table was broken. She stated that any broken furniture in the residents' rooms should be put in the maintenance log to be repaired. Additionally, Staff B stated, the toilet in the resident's room frequently requires plunging and has flooded onto the floor.Record review of a maintenance log, that is kept at the nurse's station, dated 6/2/2026 through 6/9/2026, failed to reveal evidence that the resident's broken bedside table was in documented in the maintenance log.During a surveyor interview on 6/11/2026 at 11:27 AM with a [NAME] (janitor), Staff C, he stated that he is responsible for cleaning the hallways, nurses' stations and the day room (general sitting area on the unit). Additionally, Staff C indicated that they do not clean residents' rooms, they are cleaned by the housekeeping staff.During a surveyor interview on 6/11/2026 at 11:44 AM with a housekeeper, Staff D, she stated that the housekeeping role includes cleaning the residents' rooms, bathrooms including the toilets, sweeping, and mopping the floors. Staff D further stated that the residents' rooms and bathrooms are cleaned daily and if there are spills or areas that are expected to be clean after the housekeeping staff have completed their task, the NAs are expected to clean up those areas.During a surveyor interview on 6/11/2026 at 11:57 AM, with the Maintenance Director, he was unable to provide evidence that Resident ID #152's bedside table had been repaired or that his/her floor had been cleaned, prior to it being brought to the facility's attention by the surveyor. 4. Record review revealed Resident ID #75 was admitted to the facility in April of 2024 with a diagnosis including, but not limited to, schizoaffective disorder. During a surveyor interview on 6/8/2026 at 1:19 PM, with Resident ID #75, s/he revealed that the staff does not regularly wash his/her room floor.During a surveyor observation immediately following the above-mentioned interview, cereal was observed on the floor in the resident's room and the floor was sticky.5. Record review revealed Resident ID #106 was admitted to the facility in November of 2025 with a diagnosis including, but not limited to, paranoid schizophrenia.During surveyor observations on 6/8/2026 at 1:39 PM and on 6/9/2026 at 8:27 AM, of Resident ID #106's room, revealed dark red and brown smears on the floor measuring approximately 1 foot (ft.) by 1ft. in length and two smaller smears were observed towards the bathroom.During a surveyor interview on 6/11/2026 at 12:06 PM with the Director of Nursing Services, she was unable to provide evidence that the facility provided a safe, functional, sanitary, and comfortable environment for the residents, as required.

Based on record review and staff interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections relative to the pneumonia vaccine policy's failure to align with current guidelines, as recommended, by the Advisory Council on Immunization Practices (ACIP) and Centers for Disease Control and Prevention (CDC).Findings are as follows:Review of an undated facility policy titled, Resident Vaccination (Flu and pneumonia) states in part, .Vaccinations are to be provided in accordance with the most recent ACIP (Advisory Council on Immunization Practices) guidelines for these vaccinations. As of 2014, ACIP has recommended the following pneumonia vaccination schedule (Also follow CDC Vaccination for Elders guidelines): Persons [AGE] years of age or over who have never received a pneumonia vaccination should receive PCV13.According to current ACIP guidelines and the CDC, as of 2/25/2026 the pneumonia vaccine, PCV13, is no longer recommended to be administered as a pneumonia vaccine.During a surveyor interview on 6/10/2026 at 1:45 PM with the Infection Preventionist, she revealed that the above-mentioned facility policy is their most current and includes PCV13. Additionally, she acknowledged that their policy is not up to date with current guidelines.During a surveyor interview on 6/10/2026 at 1:50 PM with the Administrator, in the presence of the Director of Nursing Services, they were unable to provide evidence that their facility policy relating to pneumonia vaccination aligns with current guidelines.

Based on surveyor observations, clinical record reviews, and staff interviews, the facility failed to ensure that services were provided in accordance with professional standards of quality relative to not following physician orders, for 3 of 3 residents. This included failing to change a wound dressing daily, as ordered, for Resident #10, failing to implement interventions related to weight loss, for Resident #11, and failing to provide seizure pads while in bed, as ordered, for Resident #157.Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing page 314, which states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.1. Record review revealed Resident ID #10 was admitted to the facility in October of 2025 with a diagnosis including, but not limited to, spinal stenosis (the narrowing of the spaces within the spine, which places pressure on your spinal cord and the nerves that branch out to the body).Record review of a physician's order dated 4/15/2026, revealed to cleanse the third and fourth toes on the left foot with a wound cleanser, apply wound gel, and cover with an island border gauze (wound dressing) every evening.Record review of the June 2026 Treatment Administration Record (TAR) revealed the order was signed off as being completed on 6/10/2026.During a surveyor observation on 6/11/2026 at 9:35 AM, the resident was observed in bed with a dressing to his/her left foot that was dated 6/9/2026, with staff initials indicating PT.During a surveyor observation on 6/11/2026 at 9:47 AM, in the presence of the third-floor unit manager, Staff E, she acknowledged the dressing on the resident's left foot was dated 6/9/2026.During a surveyor interview immediately following the above-mentioned observation, Staff E indicated that she would expect the dressing to be changed daily, as ordered, and initialed by the nurse who completed the treatment.During a surveyor interview on 6/11/2026 at 11:16 AM with Licensed Practical Nurse, Staff F, she acknowledged that she did not change the resident's dressing on 6/10/2026, as ordered. Additionally, Staff F acknowledged that she had inaccurately signed off the order as being completed on 6/10/2026, even though she did not complete the dressing change.During a surveyor interview on 6/11/2026 at 11:35 AM with the Director of Nursing Services (DNS), she stated that she would expect the resident's dressing to be changed daily, as ordered.2. Record review revealed Resident ID #11 was admitted to the facility in October of 2025 with diagnoses including, but not limited to, major depressive disorder and hereditary spastic paraplegia (progressive genetic disorders characterized by chronic weakness, stiffness, and cramping in the leg muscles).Record review of a quarterly Minimum Data Set assessment dated [DATE], revealed that the resident is dependent on staff for eating and s/he weighs 97 pounds (lbs.).Record review revealed the following weights were obtained:- 6/2/2026 and 6/3/2026: 84.2 lbs. - 5/4/2026: 97.2 lbs.Record review of a physician's progress note dated 6/5/2026, revealed a visit was completed for a significant unintentional weight loss, and the resident was found to be cachectic (a state of physical wasting, severe weight loss, and extreme muscle weakness caused by a serious underlying illness) in appearance. Additionally, the progress note revealed that a recent medication change was completed which included an order for Remeron (a medication prescribed to treat depression and frequently used to stimulate appetite).Record review of a nursing progress note authored by the Unit manager (UM), Staff E dated 6/5/2026, revealed the resident had a 13 lb. weight loss since the last monthly weight and there is a new order for Remeron 7.5 milligram (mg), daily at bedtime for appetite stimulation.Record review of a nutrition/dietary progress note dated 6/7/2026, revealed the nursing staff reported that on 6/2/2026 the resident weighed 84.2 lbs. which is 13.3% weight loss over a month. Additionally, the note revealed that the resident was started on Remeron.During a surveyor interview on 6/9/2026 at approximately 12:20 PM, with Licensed Practical Nurse, Staff G, she revealed that the resident has been losing weight and that s/he is receiving Remeron to improve his/her appetite.Record review failed to reveal evidence that the Remeron order was initiated, or the resident's responsible party had been notified to approve the Remeron order from 6/5/2026, until it was brought to the facility's attention by the surveyor on 6/9/2026.During a surveyor interview on 6/10/2026 at 11:42 AM, with UM, Staff E, she was unable to provide evidence the order for Remeron had been implemented since 6/5/2026, as she had indicated in her progress note on 6/5/2026.During a surveyor interview on 6/11/2026 at 11:43 AM, with the DNS, she revealed that she would expect the staff to have notified the resident's responsible party for approval of the new order for Remeron when the order was given by the provider on 6/5/2026. Additionally, the DNS stated that the staff is expected to notify the responsible party on the same day or the following day.3. Record review revealed Resident ID #157 was admitted to the facility in September of 2024 with diagnoses including, but is not limited to, fracture skull and cerebral edema (swelling of the brain).Review of a care plan dated 2/25/2025, revealed the resident is at risk for skin impairment related to fragile skin. Staff intervention includes, but not limited to, applying seizure pads to bed rails for safety.Record review revealed a physician order dated 9/13/2024 for bilateral seizure pads on upper side rails while in bed related to tremors for safety and injury prevention.Surveyor observations on the following dates and times the resident was observed in bed without the bilateral seizure pads on the bed rails, as ordered:- 6/8/2026 at 1:34 PM- 6/9/2026 at 8:41 AM, 8:57 AM, 11:12 AM, and at 1:09 PMDuring a surveyor observation and interview on 6/09/2026 at aproximately 1:46 PM, in the presence of Registered Nurse, Staff H, she acknowledged that the resident was in bed and the seizure pads were not on the bed rails, as ordered. Additionally, she acknowledged that she had signed off the TAR on 6/9/2026 indicating that the resident's seizure pads were on the bed rails when they were not. During a surveyor interview on 6/10/2026 at 1:07 PM, with the DNS, in the presence of the Administrator, she was unable to provide evidence that the resident's seizure pads were on his/her bed rails, as ordered. Additionally, the Administrator stated that she would expect the nurse to verify that the seizure pads were on the bed rails before signing off the order on the TAR.

Based on clinical record review, surveyor observation, and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to 1 of 1 resident reviewed who complained of chest pain and requested a hospital transfer, Resident ID #104.Findings are as follows:Review of a community report complaint submitted to the Rhode Island Department of Health on 6/15/2026 alleged Resident ID #104 was hospitalized after s/he had walked from the facility to a nearby building to have someone call 911. Further review of the complaint alleged the facility staff would not call an ambulance for the resident who thought s/he was having another stroke as s/he was feeling unwell with shortness of breath and pain. Additional review alleged that the resident reported that s/he refused to allow the nursing staff at the facility to take his/her vital signs because s/he felt unsafe, however s/he felt unwell and needed to go to the hospital.Record review revealed Resident ID #104 was admitted to the facility in March of 2026 with diagnoses including, but not limited to, hypertension (high blood pressure) and a history of a Transient Cerebral Ischemic Attack (TIA- a temporary blockage of blood flow to the brain, often referred to as a mini-stroke, and serves as a critical warning sign for potential future strokes).Review of a Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 13 out of 15, indicating intact cognition.Record review of the Medical Orders about Life-Sustaining Treatment (MOLST), signed by the resident on 3/29/2026, revealed that in the event of cardiac or respiratory arrest, do not resuscitate. Further review revealed the resident wished to be transferred to the hospital when necessary. Review of a progress note dated 6/12/2026 at 6:43 AM, authored by Registered Nurse (RN), Staff T, revealed the resident went to the nurse's station around 2:00 AM complaining about his/her roommate then spent the rest of the night sitting in a chair dozing on and off. Further review revealed a few hours later the resident approached the nurse stating that s/he was experiencing chest pain and the nurse wanted to obtain vital signs, however the resident became angry and walked away. Additional review revealed about 10 minutes later the resident was seen in the reception area and moments later staff stopped him/her as s/he was going into the street, the rescue was called and the resident was sent to the hospital.During a surveyor interview on 6/16/2026 at 10:13 AM with RN, Staff T, she revealed that on 6/12/2026 around 4:00 AM, Resident ID #104 complained of chest pain and requested to go to the hospital. She revealed that she told the resident that she needed to obtain vital signs and call the doctor and the resident said whatever and walked away. She further revealed that approximately an hour later she observed the resident walking around the facility's reception area and that the resident usually wasn't up at that time. Staff T revealed that she received a call from the Administrator at approximately 6:00 AM, informing her that the resident had left the building and another nurse was going down the street after him/her. Furthermore, she revealed that she failed to contact a provider or send the resident to the hospital after the resident had complained of chest pain at approximately 4:00 AM.During a surveyor interview on 6/16/2026 at 10:31 AM, with Licensed Practical Nurse (LPN), Staff U, she revealed that she was working on the ground floor on the morning of 6/12/2026 when the cook alerted her that a resident was seen walking down the steep street away from the facility at approximately 6:00 AM. She further revealed that when she exited the facility initially, she couldn't see the resident and another staff member pointed to indicate that the resident had turned onto a nearby street. Staff U revealed that she caught up with the resident on the street with another staff member following in a car and attempted to talk to the resident, however s/he was angry and said that s/he was going to the hospital. She revealed that the resident was sweating and continued to walk at a fast pace until s/he arrived at an apartment complex, approximately a half mile from the facility. Furthermore, she revealed that the physical therapy staff called 911 at that time, emergency medical staff and the police arrived at the apartment complex, and the resident was transported to the hospital.During a surveyor interview on 6/16/2026 at approximately 11:40 AM, with Physical Therapy Assistant, Staff V, she revealed that shortly after 6:00 AM on 6/12/2026 she was notified that a resident was walking down the street away from the facility so she drove down the street with another staff member until she found the resident, at which time she exited the vehicle and started walking with the resident. She further revealed that once they arrived at the apartment complex the resident was asking people there to call 911 so at that time, she herself contacted 911 for the resident. During a surveyor interview on 6/16/2026 at 11:50 AM with the Cook, Staff W, he revealed that around 6:00 AM on 6/12/2026 a Dietary Aide, Staff X, entered the building and indicated that he observed a resident walking down the street away from the facility. He further revealed that he exited the building and observed the resident walking down the street. He then went inside to alert a nurse as the dietary aide went down the street after the resident.Review of the EMS (Emergency Medical Service) Patient Care Report dated 6/12/2026, revealed EMS was dispatched at 6:19 AM and responded to an apartment building where the resident was sitting on a bench experiencing chest pain. Further review revealed the resident stated his/her chest pain level was five out of ten that began approximately 6 hours prior. Additional review revealed an intravenous (IV) catheter was established, aspirin was administered by mouth, and nitroglycerin spray (a medication prescribed to treat chest pain by relaxing the blood vessels) was administered sublingually (under the tongue) enroute to the hospital, where the resident was transferred to the emergency department.Review of the hospital documentation with a discharge date of 6/15/2026, revealed the resident presented to the emergency department on 6/12/2026 with chest pain and was noted to have worsening dysarthria (slow or slurred speech) and subtle right sided facial weakness at 7:15 AM. Further review revealed a CT (computed tomography) scan was performed with results indicating a stable thrombosed left internal mammary artery aneurysm (a potentially life threatening vascular lesion of the artery that supplies the chest wall and heart often associated with underlying vascular disease) and no large vessel occlusion. The resident was admitted to the hospital on [DATE] to rule out a TIA (Transient Ischemic Attack, a temporary blockage of blood flow to the brain, often referred to as a mini-stroke) or acute ischemic stroke. Additionally, the resident was discharged on 6/15/2026 to a different skilled nursing facility per the resident's request with the diagnosis of a suspected acute subcortical stroke (a stroke that occurs in the deep regions of the brain). Furthermore, the resident was discharged with a new order for aspirin daily (a medication prescribed to assist in preventing a heart attack or stroke).During a surveyor interview on 6/16/2026 at 12:44 PM, with the Medical Director, he stated that he was made aware that the resident went AWOL (Absent Without Official Leave) and then sent to the hospital via 911 on 6/12/2026 when he entered the facility later that day. He further stated that he did not think another provider was contacted prior to him entering the building on 6/12/2026. Additionally, he stated that he would expect the nurse to contact the on-call provider if a resident complains of chest pain and that it is the standard of practice to notify a resident's power of attorney (POA) when they are sent to the hospital.During a surveyor interview on 6/16/2026 at approximately 12:20 PM and at 2:43 PM with the Administrator, in the presence of the Director of Nursing Services, she revealed the resident left the faciity on the morning of 6/12/2026 because s/he wanted to go to the hospital. She further acknowledged that the nurse did not call 911 or notify the provider following the resident's complaints of chest pain on 6/12/2026. Additionally, she could not provide evidence that the resident's POA was notified when the resident unexpectedly left the facility and was admitted to the hospital.

Based on surveyor observation, clinical record review, and staff and resident interviews, the facility failed to provide treatment and care to maintain good foot health for 1 of 1 resident reviewed who complained of foot pain who is a type II diabetic and has a history of diabetic foot ulcers, Resident ID #40.Findings are as follows:Record review revealed the resident was admitted to the facility in December of 2021. Review of a Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 9 out of 15, indicating moderately impaired cognition. Further review revealed the resident is dependent on staff for activities of daily living including bathing, and applying and removing footwear. Review of the care plan revealed the resident has a potential for skin impairment related to fragile skin.Review of a weekly body check dated 6/3/2026 failed to reveal evidence of any skin impairments to the resident's feet. Further review revealed the resident's nails toenails were cut.During surveyor observations and interviews with the resident on 6/8/2026 at 11:46 AM, 6/9/2026 at 12:47 PM, and 6/10/2026 at approximately 8:30 AM, the resident complained of foot pain and stated that s/he had pulled his/her toenail off a couple of weeks ago. Observations revealed his/her left great toe without a toenail and a dark, discolored area where the nail should be. Additional observations revealed a dark colored, raised area on the top of the resident's right third toe. Record review failed to reveal evidence that the above-mentioned impairments of the resident's toes were identified by the facility, or that a treatment was in place.Review of a podiatry exam dated 4/8/2026, revealed the resident was an increased risk of infection and seen for diabetic foot care. Further review revealed that the resident's left and right great toenails were thick and yellow, and the right and left 2nd through 5th toenails were elongated. Additional review failed to reveal any toenails were missing or any open areas were noted. During a surveyor interview and observation on 6/10/2026 at 8:59 AM, with Nursing Assistant (NA), Staff I, he revealed that he provided foot care for the resident on 6/9/2026 and did not notice any new areas on the resident's feet. At this time Staff I and the surveyor observed the resident's feet with a left great toenail missing with dark discoloration to the area and a dark area on the top of the resident's right 3rd toe. Staff I stated that the impairments on the resident's feet had been there for approximately a week and that the nurse is aware of the areas. During a surveyor interview and observation on 6/10/2026 at 9:03 AM, with Licensed Practical Nurse, Staff B, she indicated that the resident frequently picks at his/her skin and that the last time she assessed the resident's feet they were rough and dry. After observing the resident's feet in the presence of the surveyor, Staff B revealed that the resident's left great toe was always discolored but she was unable to recall if s/he had a toenail. Additionally, she revealed that she was unaware of the dark, raised area to the resident's 3rd toe and that there was not a treatment in place for the area. Record review of the progress notes revealed the following:-6/10/2026- .assessments done to bilateral toes with left great toe discoloration due to no toe, right foot 3rd toe with dry blood, MD [name redacted] notified, and wound nurse assess area with this nurse. order for skin prep to right foot 3rd toe bid [twice a day].-6/10/2026- .vashe wash [a wound cleanser] to right foot 3rd toe f/b [followed by] skin prep [a fast-drying sterile liquid that forms a protectant film on the skin] bid until healed.-6/11/2026- .resident's L [left] great toenail is missing. Nurse measured the scabbed area being 1.7 [centimeters-cm] by 1[cm]. Reported to Optum NP [Nurse Practitioner] New orders in place to monitor toe for s/sx [signs and symptoms] of infection [times] 1 week and then reassess, continue with tx [treatment] to R [right] 3rd toe [times] 1 week and reassess.obtain Podiatry consult.During a surveyor interview on 6/11/2026 at 10:58 AM, with Optum NP, Staff J, she revealed that she last assessed the resident on 5/28/2026 and had not been aware of any skin impairments to the resident's toes. She further indicated that she would assess the resident's skin that day.Record review of the Optum NP note dated 6/11/2026, revealed the resident was assessed and the left great toe was noted to be missing a toenail with a very short nail at the base, black discoloration in place of the nail, and blanchable redness to the left heel. Further review revealed the right 3rd toenail was missing with dark dried drainage at the base, which appeared to be dried blood and a healed dry brown scab on the right heel. Additional review revealed a plan for treatment which included; applying vashe wash and skin prep to the right 3rd toe as ordered, monitoring for skin infections, obtaining a podiatry consult, offloading both heels, and apply skin prep to bilateral heels daily.During a surveyor interview on 6/11/2026 at 12:06 PM, with the Director of Nursing Services, she revealed that she would have expect the NA to notify the nurse when a new skin impairment was observed and the provider would be notified. Additionally, she could not provide evidence that treatment and care was provided to maintain good foot health as evidence by the new skin impairments to the resident's toes which had not been assessed and treated timely.

Based on surveyor observations, clinical record review, and staff interview, the facility failed to complete quarterly smoking assessments for 2 of 5 residents reviewed who smoke, Resident ID #s 79 and 116. Findings are as follows:Review of a facility policy titled Smoking dated 5/15/2025, states in part, .To ensure that the resident that smokes is able to do so safely and in a manner that protects the safety and rights of others.Residents who request to smoke are assessed for their capability of safely handling the smoking materials, effectively lighting the cigarette, hold the cigarette while smoking and safely extinguish the cigarette.An assessment will be completed upon any resident who expresses an interest in smoking.completed quarterly, or when there is a change in mental and/or physical status.1. Record review revealed Resident ID #79 was admitted to the facility in October of 2025 with a diagnosis including, but not limited to, chronic obstructive pulmonary disease (COPD).Record review revealed a Smoking - Safety Screen was completed on 10/24/2025. Further review revealed the resident required assistance to go to the smoking area and supervision while smoking.Record review failed to reveal evidence of a care plan relative to smoking or implementation of any related safety interventions.Record review failed to reveal evidence any quarterly smoking assessments following the above-mentioned admission assessment, indicating two assessments were not completed, as required.During a surveyor interview on 6/11/2026 at 12:06 PM, with the Director of Nursing Services (DNS), she revealed that she would expect smoking assessments to be completed quarterly and smoking care plans in place.2. Record review revealed Resident ID #116 was initially admitted to the facility in August of 2020 and readmitted to the facility following a hospitalization in June of 2026 with diagnoses including, but not limited to, COPD, dementia, and weakness.Review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 10 out of 15, indicating moderately impaired cognition.Record review of a care plan initiated 7/21/2021 revealed the resident is a supervised smoker.Record review of the progress notes revealed the resident was admitted to the hospital on [DATE] with the diagnosis of sepsis. Further review revealed the resident was readmitted to the facility on [DATE]. Record review of a provider note, with a service date of 6/5/2026, revealed the resident had bilateral upper extremity tremors that were chronic but worsening and affecting his/her activities of daily living. Record review revealed a Smoking-Safety Screen dated 5/16/2025, indicating that the resident required supervision when smoking.Further record review failed to reveal any quarterly smoking assessments were completed following the above-mentioned assessment until 5/8/2026, indicating in three quarterly assessments were not completed, as required.Record review of a Smoking-Safety Screen dated 5/8/2026 revealed the resident was safe to smoke without supervision. During a surveyor observation on 6/9/2026 at 2:12 PM, Resident ID # 116 dropped his/her lit cigarette out of his/her hand twice and required assistance from staff to pick it up.Review of a Smoking-Safety Screen dated 6/9/2026 at 2:38 PM, after the surveyor observation, revealed the resident required a smoking apron and supervision for safety while smoking due to a decrease in physical mobility and strength.During a surveyor interview on 6/10/2026 at 9:59 AM, with Licensed Practical Nurse, Staff K, he revealed that smoking assessments should be completed quarterly, if there is a change in the resident's status, or if an incident occurs. Additionally, he stated that he could not locate any completed quarterly smoking assessments between 5/16/2025 and 5/8/2026.During a surveyor interview on 6/10/2026 at 11:27 AM, with the DNS, she could not provide evidence quarterly smoking assessments had been completed between 5/16/2025 and 5/8/2026. Additionally, she acknowledged that a smoking assessment had been completed on 6/9/2026 and that the resident now requires a smoking apron for safety while smoking.

Based on clinical record review and staff interview, the facility failed to ensure that residents who are trauma survivors, receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents experiences, and preferences, in order to eliminate, or mitigate triggers that may cause re-traumatization of the resident, for 1 of 1 resident reviewed with a history of trauma, Resident ID #13. Findings are as follows:Record review revealed that the resident was readmitted to the facility in April of 2026 with diagnoses including, but not limited to, post-traumatic stress disorder (PTSD) and anxiety.Review of a Minimum Data Set assessment, Section I Active Diagnosis dated 4/20/2026, revealed PTSD and Anxiety.Review of a Psychiatric Evaluation and Consultation dated 4/7/2026 revealed an active diagnosis of PTSD.Record review failed to reveal evidence of a care plan for PTSD to mitigate triggers that may cause re-traumatization.During a surveyor interview on 6/10/2026 at 12:22 PM, with Social Worker, Staff L, she revealed that she was aware the resident had a diagnosis of PTSD from a previous admission but did not implement a care plan for the PTSD on his/her most recent admission because it was not listed on his/her most recent admission paperwork.During a surveyor interview on 6/11/2026 at 12:06 PM, with the Director of Nursing Services, she acknowledged that the resident has a diagnosis of PTSD and does not have a care plan in place.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that bed rails were used only when assessed, clinically indicated, and implemented in accordance with the resident's needs for 2 of 2 residents reviewed with bed rails, Resident ID #s 124 and 158.Findings are as follows:Review of a facility policy titled, Side Rail Use last revised 8/29/2023, states in part, .This facility recognizes the potential for the hazard of entrapment related to side rail use. It is our policy therefore, to eliminate or minimize the use of side rails. Prior to installing side rails, we will utilize appropriate alternatives. If side rails are used an appropriate assessment as to the risk for entrapment and safety will be done.Informed consent will be obtained.1. Record review revealed Resident ID #124 was admitted to the facility in January of 2026 with a diagnosis including, but not limited to, Huntington's disease (a disorder that causes certain nerve cells in the brain to stop working properly. It leads to mental deterioration and loss of control over major muscle movements).Record review of the Quarterly Minimum Data Set assessment (MDS) dated [DATE], revealed a Brief Interview for Mental Status score of 00 out of 15, indicating severe cognitive impairment. Further review revealed that s/he required substantial to maximal assistance for bed mobility.Review of a facility assessment titled, Side Rail Assessment and Consent form 2.0- V2 dated 4/13/2026, states the following, .Medical condition to require the use of side rails: none.Reason for side rail usage: none.Resident can demonstrate proper use of device: No.Type of rails to be used: none.Risk and Benefits: N/A (Not Applicable).Surveyor observations on 6/8, 6/9, 6/10, and 6/11/2026 revealed the resident has bilateral bed rails.During a surveyor interview on 6/10/2026 at 11:17 AM, with the Director of Nursing Services (DNS), she acknowledged that Resident ID #124 has side rails. She further revealed that she would have expected the bed rail assessment to be completed with the appropriate consent.2. Record review revealed Resident ID #158 was admitted to the facility in February of 2026 with a diagnosis including, but not limited to, Alzheimer's disease.Record review of the Quarterly MDS dated [DATE], revealed a Brief Interview for Mental Status score of 00 out of 15, indicating severe cognitive impairment. Further review revealed that s/he was dependent on staff for bed mobility.Review of a facility assessment titled, Side Rail Assessment and Consent form 2.0- V2 dated 6/7/2026, states the following, .Medical condition to require the use of side rails: Alzheimer's disease.Reason for side rail use: Boundary Limitations.Resident can demonstrate proper use of device: No.Type of rails to be used: Two half side rails.Frequency of use: daily .Surveyor observations on 6/8, 6/9, 6/10, and 6/11/2026 revealed the resident has bilateral bed rails.During a surveyor interview on 6/10/2026 at approximately 10:49 AM, with the Unit Manager, Staff M, she revealed that the resident has bilateral side rails because the family requested them. She further revealed that the resident was dependent on staff for bed mobility and could not independently utilize the bed rails and acknowledged that the physician's order did not accurately reflect the resident's use of the devices. She further acknowledged that the facility would not typically implement bed rails for a resident who is unable to use them.During a surveyor interview on 6/10/2026 at 11:17 AM, with the DNS, she revealed that she was unsure what the meaning of boundary limitations in the side rail assessment. She further acknowledged that the order for bed rails is not accurate and that the resident cannot use them appropriately.

Based on surveyor observation, clinical record review, and staff interviews, the facility failed to ensure each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 27 opportunities for errors observed during the medication administration task, 2 errors occurred, resulting in an error rate of 7.41% affecting Resident ID #s 128 and 133.Findings are as follows:Review of a facility policy titled, Medication Administration dated 10/11/2017, states in part, .Medications ordered to be given according to specific parameters must reflect the results of testing, i.e. [in other words] blood pressure.Prepare medications for the resident following the instructions on the MAR [Medication Administration Record].1a. Record review revealed Resident ID #133 has a physician's order to administer furosemide 40 milligrams, one tablet in the morning, for high blood pressure. Additionally, special instructions include blood pressure parameters to hold the medication if the resident's systolic blood pressure (top number) is less than 90 or if the diastolic blood pressure (bottom number) is less than 50.During a surveyor observation of the medication administration task on 6/9/2026 at 9:35 AM, with Licensed Practical Nurse (LPN) , Staff N, he failed to obtain the resident's blood pressure and was prepared to administer the resident's furosemide until he was stopped by the surveyor.During a surveyor interview immediately following the above observation with Staff N, he revealed that he had administered the resident another blood pressure medication at approximately 8:00 AM that morning and had assessed his/her blood pressure at that time. He revealed that he was using the same blood pressure reading that he obtained approximately 90 minutes earlier as his reference. Staff N indicated that he should be reassessing the resident's blood pressure immediately prior to administering the furosemide. Further, he revealed that it is his normal practice to not re-assess the resident's blood pressure and to use prior blood pressure readings.1b. Record review revealed Resident ID #128 has a physician's order to administer Lactaid (a digestive enzyme) 3,000 units, one tablet, three times daily for lactose intolerance.During a surveyor observation of the medication administration task on 6/9/2026 at 10:26 AM with Certified Medication Technician, Staff O, he was observed to have administered one Lactaid tablet to the resident from the facility's house stock. Record review, upon completing the medication reconciliation for Resident ID #128, revealed the facility's house stock Lactaid tablets are 9,000 units per tablet.During a surveyor interview on 6/9/2026 at 1:23 PM with LPN, Staff N, he acknowledged that the facility's house stock Lactaid tablets are 9,000 units and the resident's order is to administer 3,000 units. Additionally, he revealed that the facility's house stock Lactaid tablets are the only Lactaid tablets that he uses to administer to the residents.During a surveyor interview on 6/9/2026 at 1:54 PM with the Director of Nursing Services, she revealed that she would expect staff to re-assess Resident ID #133's blood pressure at the time of his/her furosemide administration and for Resident ID #128 to have received the correct dose of Lactaid.

Based on record review and staff interview, it has been determined that the facility failed to accurately maintain the resident's medical record in accordance with accepted professional standards and practices relative to 1 of 1 closed record missing a discharge summary, Resident ID #171.Findings are as follows:Record review revealed the resident was admitted to the facility in July of 2024 with diagnoses including, but not limited to, atrial fibrillation (irregular heartbeat) and diabetes. Record review of the progress note revealed a nursing entry indicating that the resident was found diseased in his room and pronounce dead at 7:50 PM on 3/16/2026.During a surveyor interview on 6/10/2026 at 12:41 PM, with Social Worker, Staff P, she was unable to provide evidence that a discharge summary was completed.During a surveyor interview on 6/10/2026 at 1:40 PM, with Medical Records, Staff Q, she was unable provide evidence that a discharge summary was completed. During a surveyor interview on 6/10/2026 at 2:39 PM and 6/11/2026 at approximately 12:00 PM, with the Administrator, she revealed that she would expect the discharge summary to be completed within 2-3 weeks or within 30 days and she was unable to provide evidence that a discharge summary had been completed.

Based on clinical record review, surveyor observation, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and the use of Enhanced Barrier Precautions (EBP; refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO] that employs targeted gown and glove use during high contact resident care activities), for 2 of 2 residents reviewed with wounds, Resident ID #s 63 and 93, and for 1 of 1 resident reviewed with a Peripherally Inserted Central Catheter (PICC, a long, flexible, thin tube inserted through a vein in the upper arm and advanced into a large vein near the heart) Resident ID # 66.Findings are as follows:Review of a facility policy titled, Isolation dated 2/17/2025 states in part, Enhanced Barrier Precautions- This level of precaution expands the use of PPE [personal protective equipment] beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDRO [Multi Drug Resistant Organism] to staff hands and clothing.residents with chronic un-healing wounds or indwelling medical devices regardless of their MDRO colonization status will be on Enhanced Barrier Precautions for the duration of their stay or until the resolution of the wound or discontinuation of the indwelling medical device. Examples of high contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include.device care of use: central line.wound care: chronic.1a. Record review revealed Resident ID #63 was admitted to the facility in December of 2025 with a diagnosis including, but not limited to, obesity.Record review revealed a Wound Evaluation and Management Summary dated 6/2/2026, indicating Resident ID #63 has the following wounds:-Stage II Pressure Ulcer to the right ischium (a pair of bones forming the back of the hip bone) measuring 0.9 centimeters (cm) X 1.5 cm X 0.1 cm with light serous drainage (a clear or yellow fluid that leaks out of a wound).-Stage II Pressure Ulcer to the left ischium measuring 0.5 cm X 0.9 cm X 0.1 cm with light serous drainage.Review of a physician's order for wound care to the right and left ischium dated 4/8/2026, revealed to apply triad mixed with Silvadene (an antibiotic) and cover with an island border gauze, 1 time per day and as needed.Review of a care plan dated 2/17/2026, revealed the resident has wounds and is on enhanced barrier precautions with an intervention including, but not limited to, gloves and gown donned prior to high-contact care activities.Surveyor observations on all days of the survey failed to reveal Resident ID #63 was on EBP.During a surveyor observation on 6/10/2026 at 9:23 AM, with Registered Nurse (RN), Staff R, she went into the resident's room to perform wound care. Staff R did not wear a gown during wound care.During a surveyor interview immediately following the above-observation, Staff R acknowledged that she did not wear a gown during wound care. Per Staff R she was unaware the resident was on EBP due to there being no signage outside of his/her room.During a surveyor interview on 6/10/2026 at approximately 10:30 AM, with the Infection Preventionist, she acknowledged that Resident ID #63 is not on enhanced barrier precautions, although, s/he has wounds.1b. Record review revealed Resident ID #93 was admitted to the facility in September of 2023 with a diagnosis including, but not limited to, Alzheimer's disease.Record review revealed the following physician's orders:-cleanse right hand wound with wound spray, apply bacitracin and cover with small gauze, followed by kling wrap daily and as needed for soiling.-Cephalexin (antibiotic) oral tablet 250 milligrams two times a day for infection to right hand wound.Surveyor observations on all days of the survey failed to reveal evidence that the resident was on EBP.During a surveyor observation on 6/9/2026 at 12:20 PM, in the presence of Licensed Practical Nurse (LPN), Staff G, the resident was observed in the dining room with an exposed wound on his/her right hand with visible light-colored fluid drainage seeping from the wound.During a surveyor interview immediately following the above observation, Staff G acknowledged that the resident has a wound on his/her right hand that was draining. During a surveyor interview on 6/11/2026 at 9:35 AM, with RN, Staff S, she stated that she had changed Resident ID #93's dressing that day and did not wear a gown because she was unaware the resident was on EBP, as there was not any signage on the resident's door.During a surveyor interview on 6/11/2026 at 10:33 AM, with the IP, she revealed that Resident ID #93 should be on EBP due to his/her wound drainage.2. Record review revealed that Resident ID #66 was admitted to the facility in January of 2026 with a diagnosis including, but not limited to, osteomyelitis (an infection in the bone) of the right foot and ankle.Review of a physician's order dated 5/22/2026, revealed the resident is on EBP due to a PICC line and a wound.Review of a care plan dated 3/16/2026 revealed the resident is on EBP due to wounds with an intervention including, but not limited to, gloves and gown donned prior to high-contact care activities.During a surveyor observation on 6/9/2026 at 11:04 AM, with Licensed Practical Nurse, Staff N, he was observed initiating antibiotic administration through the resident's PICC line without wearing a gown, as required.During a surveyor interview immediately following the above-observation, Staff N acknowledged that Resident ID #66 was on EBP and he should have worn a gown while accessing his/her PICC line.During a surveyor interview on 6/10/2026 at 12:30 PM with the IP she revealed that she would expect staff to wear a gown when accessing a resident's PICC line.During a surveyor interview on 6/10/2026 at approximately 11:30 AM with the Director of Nursing Services she was unable to provide evidence that staff utilized enhanced barrier precautions for Resident ID #s 63, 66, and 93, as required.

Based on record review, staff and resident interview it has been determined that the facility failed to keep a resident free from neglect relative to 1 of 1 resident reviewed who was left unattended outside of the facility for approximately 3 hours and 20 minutes during a heat advisory resulting in cardiac arrest, Resident ID #1. Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 7/30/2025 alleged that Resident ID #1 was left unattended outside of the facility for an unknown amount of time on 7/30/2025. The complaint further alleged that the resident was found unconscious, without a pulse and required cardio-pulmonary resuscitation (CPR). Additionally, the resident was transferred to the hospital for further treatment.Review of the weather report on 7/30/2025 revealed a heat advisory was in effect for the facility's area. According to the National Weather Service, a heat advisory is issued when dangerously high temperatures are expected that could potentially be harmful. Record review revealed Resident ID #1 was admitted to the facility in April of 2025 with diagnoses including, but not limited to, diabetes mellitus type 2, heart failure, chronic obstructive pulmonary disease (COPD), and cognitive communication disorder. Review of a care plan last revised on 7/21/2025 revealed the resident has a level two PASRR evaluation (a person-centered comprehensive evaluation used for people with a mental illness or intellectual disability to determine the need for specialized services) related to mental illness with interventions including, but not limited to, assessing and anticipating the resident's needs such as food, thirst, toileting needs, comfort level, body positioning, and pain. Record review revealed a physician's order dated 7/4/2025 to administer Humalog injection solution (a fast-acting insulin) per the sliding scale (the nurse obtains the resident's blood sugar via a finger stick and then administers the appropriate dose of insulin ordered for that blood sugar range) three times a day, at 8:30 AM, 11:30 AM, and 4:30 PM. Record review of the July 2025 Medication Administration Record (MAR) revealed on 7/30/2025 the nurse documented N/A -1 for the 11:30 blood sugar check insulin injection. Further review revealed the code 1 on the MAR indicated that the resident was absent from home without [medications]. Additional review failed to reveal evidence that the resident refused any medications or treatments on 7/30/2025. Record review of a progress note dated 7/30/2025 at 1:50 PM indicated that the resident was found unresponsive, sitting outside in his/her wheelchair. The resident was brought in by staff at which time s/he stopped breathing, 911 was called and CPR was initiated. Further review indicated the resident became responsive at which time emergency medical services (EMS) took over.Review of the RI EMS Patient Care Report revealed EMS arrived at the facility on 7/30/2025 at 1:29 PM after a call for an unresponsive resident. Further review revealed Resident ID #1 was extremely hot to touch on arrival with shallow breathing and pinpoint pupils. Additional review revealed a facility nurse reported that the resident was outside when s/he became slumped over in his/her wheelchair for an unknown amount of time and then moved inside where staff could not find a pulse and started CPR. Resident ID #1 was transported to the hospital. Review of a hospital document dated 7/30/2025 revealed Resident ID #1 was admitted to the hospital for suspected heat stroke resulting in cardiac arrest, aspiration pneumonia (refers to adverse pulmonary consequences due to entry of gastric or oropharyngeal fluids), secondary to cardiac arrest and myocardial infarction (heart attack) in the setting of cardiac arrest. The hospital records indicate that the resident was outside in the heat for over 3 hours when s/he was found unresponsive by nursing home staff. The resident underwent multiple rounds of CPR in the field and obtained return of spontaneous circulation (ROSC). On arrival to the emergency department, the resident's heart monitor was showing pauses, and the resident was unresponsive requiring one round of CPR for which ROSC was obtained. During a surveyor interview on 7/31/2025 at approximately 2:30 PM with Nursing Assistant (NA), Staff A, in the presence of a translator, he indicated that he was assigned to perform care for Resident ID #1 on 7/30/2025. He further indicated that he provided morning care and served his/her breakfast. Additionally, he indicated that the resident went outside at approximately 10:00 AM and that he did not check on the resident after s/he went outside. Furthermore, he acknowledged that he did not look for the resident at lunch time to offer his/her meal. During a surveyor interview on 7/31/2025 at approximately 1:30 PM with Licensed Practical Nurse, Staff B, she indicated that Resident ID #1 went outside of the facility at approximately 10:00 AM on 7/30/2025. She further indicated that she did not go outside to check on the resident or attempt to complete the ordered blood sugar check that was scheduled for 11:30 AM. Additionally, she indicated that someone, she was unaware who, had told her that the resident refused to come inside so she didn't see him/her until she was alerted that s/he was outside unresponsive at approximately 1:30 PM. Furthermore, she indicated that the receptionist brought the resident inside and s/he was found to be pulseless, and CPR was initiated. Surveyor observations of the facility's surveillance camera footage of 7/30/2025, on 7/31/2025 at 9:05 AM in the presence of the Director of Nursing Services (DNS) and the Maintenance Director, revealed the resident exited the front door of the facility alone, self-propelling in his/her wheelchair at 9:56 AM. Further review revealed s/he remained in the parking lot, in the sun until 1:13 PM. At this time, another resident unsuccessfully attempted to arouse him/her and went back into the facility to get help. The receptionist then brought Resident ID #1 into the facility at 1:14 PM. Additionally, the surveillance camera footage failed to reveal evidence that any staff member was observed to approach the resident to check on him/her, offer lunch, or to obtain his/her scheduled blood sugar. Furthermore, the resident was observed to be slumped over in his/her wheelchair with his/her legs dragging on the ground when the receptionist brought him/her into the facility, 3 hours and 20 minutes after s/he exited the facility unattended, during a heat advisory. During a surveyor interview with the DNS immediately following the above observations, she acknowledged that the surveillance footage that had just been observed, did not reveal evidence that any staff members approached the resident to offer his/her lunch, obtain the blood sugar, or to encourage him/her to go back into the facility. The facility's failure to keep a resident free from neglect resulted in Resident ID #1 becoming unresponsive, requiring CPR, and subsequently being admitted to the hospital with concerns for heat stroke. This failure places Resident ID #1 at risk for serious injury, serious harm, serious impairment or death.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from significant medication errors for 1 of 1 resident reviewed receiving amoxicillin-clavalanate (an antibiotic) and divalproex (a medication used to treat mood disorders) and 1 of 2 residents reviewed requiring insulin, Resident ID #1. Findings are as follows:Review of a facility policy titled, Medication Administration dated 10/11/2017 states in part, It is the intent of this policy to ensure that resident medication administration is managed to ensure for resident quality of life, timeliness and safety .When transcribing an order to the MAR [Medication Administration Record].the nurse will take into consideration the purpose of administering the medication and assign the appropriate time.Medications are administered within one hour of the time noted on MAR .Record review revealed Resident ID #1 was readmitted to the facility in August of 2025 with diagnoses including, but not limited to, diabetes mellitus, mood disorder, and sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock and death).1a. Record review revealed a physician's order dated 8/6/2025 for amoxicillin-clavalanate 875-125 milligram (mg), take one tablet by mouth in the morning for sepsis for 9 days.Record review of the August 2025 Medication Administration Record (MAR) revealed that the amoxicillin-clavalanate was documented as not administered as ordered on 8/7/2025 with a reason code of 5 which indicates to see the progress notes. Review of a progress note dated 8/7/2025 revealed the above medication was not administered due to being on order.1b. Record review of a hospital Discharge Summary document dated 8/6/2025 revealed a physician's order to continue divalproex ER (extended release) 2,000 mg by mouth nightly. Additionally, the hospital discharge document revealed the last time the medication was administered was on 8/5/2025 at 10:27 PM indicating the next required daily dose would be on 8/6/2025 in the evening. Record review of an undated Medication Reconciliation document revealed the resident was to continue with the divalproex ER upon his/her readmission to the facility.Record review revealed a physician's order dated 8/6/2025 for divalproex ER 500 mg- give four tablets (for a total dose of 2,000 mg) by mouth at bedtime.Additional review of the August 2025 MAR failed to reveal evidence that the resident received his/her divalproex ER 2,000 mg as ordered on 8/6 or 8/7/2025.1c. Record review revealed a physician's order dated 8/7/2025 for Lantus (a long-acting insulin) 100 unit/milliliter (mL); inject 5 units in the morningFurther review of the August 2025 MAR failed to reveal evidence that the Lantus insulin was administered as ordered on 8/7/2025.During a surveyor interview on 8/22/2025 at 2:04 PM with Licensed Practical Nurse, Staff A, he acknowledged that he worked the 7:00 AM to 3:00 PM shift on 8/7/2025 and was assigned to care for the resident. Additionally, he was unable to recall if he administered the Lantus insulin to the resident as ordered. Further, he acknowledged the amoxicillin-clavalanate was not administered as ordered 8/7/2025 and that there is an in house pyxis (an automated medication dispensing system) that contained the amoxicillin-clavalanate. Furthermore, he was unable to provide evidence that the resident received the divalproex ER 2,000 MG as ordered on 8/6/2025 and 8/7/2025.During a surveyor interview on 8/22/2025 at approximately 2:30 PM and 2:56 PM with the resident's Nurse Practitioner, Staff B, she acknowledged that she was unaware that the amoxicillin-clavalanate was not administered for the full 9-day course as ordered. Additionally, she revealed that she was not aware that the resident did not receive his/her divalproex ER and Lantus as ordered and would have expected the resident to have received the medications as ordered. During a surveyor interview on 8/22/2025 at 3:40 PM with the [NAME] President of Operations, she indicated it would have been her expectation that the medication aide would have asked the nurse to remove the amoxicillin-clavalanate from the pixus to administer the medication to the resident 8/7/2025 and that the resident would have received his/her Lantus as ordered on 8/7/2025. Further she was unable to provide evidence why the residents divalproex ER was not administered on 8/6/2025 and 8/7/2025.Cross Reference- F658

Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided by the facility meet professional standards of quality relative to following physician's orders for 1 of 3 residents reviewed, Resident ID #1.Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing, page 314, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.Record review revealed Resident ID #1 was readmitted to the facility in August of 2025 with a diagnosis including, but not limited to, diabetes mellitus.1a. Record review revealed a physician's order dated 8/7/2025 for Humalog Insulin (a short acting insulin); 100 unit/milliliter (mL); before meals inject as per sliding scale:-Blood Sugar is 150 to 199, give 2 Units. -Blood Sugar is 200 to 249, give 4 Units. -Blood Sugar is 250 to 299, give 6 Units. -Blood Sugar is 300 to 349, give 8 Units. -Blood Sugar is greater than 350, call MD (medical doctor).Record review of the August 2025 Medication Administration Record (MAR) failed to reveal evidence that the resident's blood sugar was obtained to determine if the Humalog insulin was required to be administered on the following dates and times: -8/7/2025 at 11:30 AM -8/10/2025 at 6:30 AM 1b. Record review revealed a physician's order dated 8/20/2025 for a high protein snack at bedtime for nutritional support.Record review of the August 2025 MAR revealed the high protein snack was documented as not available and not provided to the resident on the following dates:-8/20/2025-8/21/2025During a surveyor interview on 8/22/2025 at 2:04 PM with Licensed Practical Nurse, Staff A, he was unable to explain why the resident did not receive his/her high protein snack as ordered and acknowledged that the items were available in the facility to provide to the resident. Additionally, he was unable to provide evidence that the resident blood sugar was obtained on 8/7/2025 at 11:30 AM and 8/10/2025 at 6:30 AM as ordered. During a surveyor interview at 8/22/2025 at 3:40 PM with the [NAME] President of Operations, she revealed that items are available in the facility to give residents high protein snacks and would have expected the snack to be given as ordered. Additionally, she was unable to provide evidence that the resident's blood sugar was obtained on 8/7/2025 at 11:30 AM and 8/10/2025 at 6:30 AM as ordered to determine if the resident required his/her insulin to be administered.Cross reference F760

Based on surveyor observation, resident, and staff interview, it has been determined that the facility failed to ensure a safe environment was maintained relative to unsafe water temperatures, for 4 of 4 floors observed. Findings are as follows: According to the State Operation Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised 8/8/2024, states in part, .Some States have regulations regarding allowable maximum water temperature .Water may reach hazardous temperatures in hand sinks, showers, tubs, and any other source or location where hot water is accessible to a resident. Burns related to hot water/liquids may also be due to spills and/or immersion .skin in relation to the temperature of the water and the length of time of exposure .Time Required for a 3rd Degree Burn to Occur .133 F, 15 seconds . According to TITLE 216 - DEPARTMENT OF HEALTH, CHAPTER 40 - PROFESSIONAL LICENSING AND FACILITY REGULATION, SUBCHAPTER 10 - FACILITIES REGULATION, PART 1 - Licensing of Nursing Facilities, .In resident areas, hot water temperatures shall not be less than one-hundred degrees Fahrenheit (100 F) nor exceed one-hundred- and eighteen-degrees Fahrenheit (118 F). Thermometers [accuracy of which can be plus or minus two degrees Fahrenheit (+/-2 F)] shall be provided in each residential area to check water temperature periodically on that unit and at each site where residents are immersed or showered . Record review of a facility document titled, Water Temperatures, states in part, Resident hot water usage temperature will be kept at a level of not less than 100 degrees Fahrenheit nor exceed 118 degrees Fahrenheit per State regulations .Maintenance personnel shall monitor equipment and water supply sources to ensure that malfunctions are not occurring .Water temperatures are to be monitored not less than weekly with the following: Maintenance personnel will take water temperatures weekly with random sample .Maintenance shall provide thermometers to each unit for nursing personnel to periodically check water temperatures on their unit and where residents are immersed or showered .In the event that a non-maintenance staff member discovers a temperature out of the range (note that the range may include a plus/minus two degrees) or by touch feels that the temperature is too high or low, maintenance will be notified . During a surveyor observation on 2/24/2025 at approximately 9:33 AM on the 1st Floor, a surveyor was washing their hands in resident room [ROOM NUMBER]'s sink. The water became very hot to touch, reddening the skin of the surveyor's hands, and steam was rising from the sink. Following this observation, the water temperature was obtained using a digital thermometer and recorded a temperature of 137.5 F. During surveyor observations on 2/24/2025, immediately following the above observation, water temperatures were obtained and were found to exceed 120 degrees F: Ground Floor: -Shower room, shower 132.0 F -Resident room [ROOM NUMBER], sink 136.5 F -Resident room [ROOM NUMBER], sink 137.1 F First Floor: -Resident room [ROOM NUMBER], sink 137.1 F -Resident room [ROOM NUMBER], sink 137.7 F -Resident room [ROOM NUMBER], sink 137.5 F Second Floor: -Resident room [ROOM NUMBER], sink 137.5 F -Resident room [ROOM NUMBER], sink 133.3 F -Resident room [ROOM NUMBER], sink 133.7 F Third Floor: -Shower room, sink 133.9 F -Resident room [ROOM NUMBER], sink 135.5 F -Resident room [ROOM NUMBER], sink 136.0 F -Resident room [ROOM NUMBER], sink 133.0 F During a surveyor interview on 2/24/2025 at 9:50 AM with Nursing Assistant, Staff L, regarding the 2nd floor shower room, she acknowledged that the staff use both showers in the shower room for residents daily and stated, I don't want it to get too hot, so I only turn it up halfway. During a surveyor interview on 2/24/2025 at approximately 10:08 AM with NA, Staff M, she revealed that at times the water can get too hot. During a surveyor interview on 2/24/2025 at approximately 11:05 AM with Resident ID #9, s/he revealed that the maintenance staff recently fixed the hot water in his/her room sink and now it does not have any cold water. The resident further revealed that s/he could not use it because the water is too hot. During a surveyor interview and observation on 2/24/2025 at approximately 10:40 AM, with the Maintenance Director, the following water temperatures were obtained and found to exceed 120 degrees F: Ground floor: Resident room [ROOM NUMBER], sink 133.1 F First Floor: Resident room [ROOM NUMBER], sink 132.8 F Second Floor: Resident room [ROOM NUMBER], sink 132.8 F Third Floor: Resident room [ROOM NUMBER], sink 131.0 F During a surveyor interview immediately following the above observation with the Maintenance Director, he acknowledged the above water temperatures exceeded 120 F. During a surveyor interview on 2/24/2025 at approximately 11:21 AM, with the Administrator in the presence of the Director of Nursing Services, she acknowledged that water temperatures should not exceed 120 F. Additionally, they were unable to provide evidence that the facility to ensure a safe environment was maintained, relative to water temperatures. The facility's failure to ensure safe water temperatures throughout the facility placed the residents at risk for serious injury, serious harm, serious impairment or death.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed ensure the director of food and nutrition services met the minimum qualifications of a Certified Food Safety Manager. Findings are as follows: Record review of the Rhode Island Food Code, 2018 Edition, Section ,d+[DATE].12 Certified Food Protection Manager states in part .at least one employee that has supervisory and management responsibility and the authority to direct and control food preparation and service shall be a certified food protection manager . During the initial tour of the main kitchen on [DATE] at 8:50 AM, surveyor observations failed to reveal evidence of a certification of a Food Safety Manager for the Food Service Director (FSD). Subsequently the FSD indicated that he had obtained the required education and certification and would present it at a later date. During a surveyor interview on [DATE] at approximately 9:30 AM, the FSD presented a Certificate of Completion for a Food Handler Training Course. The surveyor informed the FSD that the document provided does not meet the requirement of a Certified Food Safety Manager as required per regulations. Additionally, the Food Handlers Certificate provided had expired on [DATE]. During a surveyor interview on [DATE] at 2:37 PM with the FSD revealed that he was unaware he did not have the required Certified Food Safety Manager certification, until brought to his attention by the surveyor. During a surveyor interview on [DATE] at 1:42 PM with the Administrator, she presented a Certificate of Completion for a Food Handler Training Course. She indicated that she was unaware of the expiration date of [DATE], and that the certification was for a Food Handler, not a Food Safety Manager, as required, until brought to her attention by the surveyor. She revealed that she was unaware the FSD did not have the required certifications upon hire in November of 2024.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that the Director of Food and Nutrition Services met the minimum qualifications of a Certified Food Safety Manager for 1 of 1 Food Service Director (FSD) reviewed. Additionally, the facility failed to ensure that food is stored and distributed, in accordance with professional standards for food safety relative to the main kitchen and 4 of 4 kitchenettes. Findings are as follows: 1. Record review of the Rhode Island Food Code, 2018 Edition, Section 2-102.12 Certified Food Protection Manager states in part .at least one employee that has supervisory and management responsibility and the authority to direct and control food preparation and service shall be a certified food protection manager . During the initial tour of the main kitchen on 2/24/2025 at 8:50 AM, surveyor observations failed to reveal evidence of a certification of a Food Safety Manager for the FSD. Subsequently the FSD indicated that he had obtained the required education and certification and would present it at a later date. During a surveyor interview with the FSD on 2/25/2025 at approximately 9:30 AM, he presented a Certificate of Completion for a Food Handler Training Course with an expiration date of 3/8/2024. The surveyor informed the FSD that the document provided does not meet the requirement of a Certified Food Safety Manager, per regulation. During a surveyor interview on 2/25/2025 at 2:37 PM with the FSD, he revealed that he was unaware that he did not have the required Food Safety Manager certification. During a surveyor interview on 2/26/2025 at 8:32 AM with the Dietitian, she revealed that she is at the facility 3 days per week on average. She indicated that she does not provide oversight of meal service including, preparing, cooking, and serving food to the residents. Record review of the facility time sheets for the dietary department for 1/1/2025 through 1/31/2025, and 2/1/2025 through 2/22/2025, revealed the following: - January time sheets failed to reveal evidence that a Certified Food Safety Manager was present during all three meal services for 20 out of 31 calendar days - February time sheets failed to reveal evidence that a Certified Food Safety Manager was present during all three meal services for 14 out of 22 calendar days During a surveyor interview on 2/26/2025 at approximately 9:30 AM with the Administrator, she was unable to provide evidence that a Certified Food Safety professional was in the kitchen during all three meal services for the months of January and February 1, 2025, through February 22, 2025. During a surveyor interview on 2/26/2025 at 1:42 PM with the Administrator, she revealed that she was unaware that the FSD did not have the required certifications upon hire in November of 2024. 2. Record review of the Rhode Island Food Code 2018 edition, Section 3-501.16 Time/Temperature Control for Safety, Hot and Cold Holding states in part, .(A) Except during preparation, cooking or cooling time/temperature control for safety food shall be maintained: (1) At 57 degrees Celsius (135 degrees Fahrenheit) or above . During a surveyor observation on 2/26/2025 at 11:25 AM of the lunch meal plating process, revealed 10 serving trays were set up on the food service line, each containing a portion of macaroni and cheese alongside zucchini. At the time of the observation, the plated food was uncovered and exposed. The trays were observed to be stationary for greater than 90 seconds while additional items were added to each tray before slowly continuing down the assembly line for the plate to be covered and then placed into carts that transport the prepared meal trays to residents across various units. During a surveyor interview and observation on 2/26/2025 with the FSD at 11:36 AM, he indicated that this procedure was the standard practice used for plating all meals. The surveyor requested the FSD to take a sample of temperatures of the plated meals on the line, which revealed the following: -A plated sliced ham steak was 128 Fahrenheit (F) -A plated portion of macaroni and cheese was 125 F Immediately following the above observation, the surveyor requested the FSD to obtain additional holding temperatures of the plated meals that were observed plated on the service line for extended time prior to being placed inside of a food cart, that was going to be delivered to one of the units for lunch service revealed the following: -Two trays containing plated portions of macaroni and cheese had temperatures of 110 F and 102 F -A tray containing a plated portion of sliced ham steak meal had a temperature of 115 F The FSD indicated that he was unaware that food holding temperatures below 135 F were potentially hazardous until informed by the surveyor. Once he was informed, he acknowledged the low holding temperatures and proceeded to push the affected cart off to the side and he then stepped away from the service area. During a surveyor observation and interview on 2/26/2025 at 11:44 AM revealed Dietary Aide, Staff Z was placing the affected cart onto the elevator and was stopped by a surveyor. Staff Z revealed to the surveyor that he was delivering the cart to the 2nd floor for lunch service. He indicated that he had not been informed by the FSD of the unsafe holding temperatures of the plated meals in the affected cart. During a surveyor interview on 2/26/2025 at 11:46 AM with the FSD, he acknowledged that the temperatures obtained for meals in the cart were below the safe holding temperature of 135 F for hot foods and he directed the dietary staff and cooks to prepare an alternate meal for the 2nd floor lunch service. 3. Record review of Rhode Island Food Code, 2018 Edition, Section 3-501.17 states in part, n .READY -TO-EAT-TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the premises, sold, or discarded . Review of the facility's policy titled, Use and Storage of Food Brought in by Visitors, states in part, .the dietary staff members assigned to routine rounds to stock/clean unit refrigerators/nutrition pantry will monitor status of food and discard perishable items that appear unsafe for consumption or older than 3 days . During the initial tour of the kitchen and 3 of 4 kitchenettes in the presence of the FSD, on 2/24/2025 at 8:20 AM, the following was observed: Main kitchen: -1 unlabeled and undated large blue bag, approximately 1/3 full of frozen croissants Ground Floor kitchenette: -2 full 64-ounce (oz) pitchers of orange juice labeled with a discard date of 2/21/2025 -2 full 64 oz pitchers of cranberry juice without a label indicating a discard date -1 half full 64 oz pitcher of orange juice without a label indicating a discard date 1st floor kitchenette: -one banana black in color in the refrigerator drawer -5 covered soup style bowls containing apple sauce, 3 labeled with discard dates of 2/19/2025 and 2 labeled with discard dates of 2/21/2025 -2 full 64 oz pitchers of apple juice with labels indicating a discard date of 2/21/2025 -1 half gallon of coffee ice cream approximately 1/4 full of substantial freezer burn without a label or indicating a discard date -1 covered soup style bowl containing diced pineapple without a label or indicating a discard date -A foil pack containing 4 slices of bread without a label or indicating a discard date -1 large Styrofoam to go container containing fried clams and French fries without a label or indicating a discard date -1 22 oz personal glass container of soup without a label or indicating a discard date -1 22 oz personal glass container of pasta without a label or indicating a discard date During a surveyor interview on 2/24/2025 at 8:50 AM with Certified Medication Technician, Staff R, following the above observations of the kitchenette, she acknowledged the food items should have been labeled, dated, or thrown away as indicated per facility policy. During a surveyor observation of the 3rd floor kitchenette on 2/25/2025 at 8:39 AM, in the presence of the FSD, the following was observed: -An unlabeled package containing 4 frozen waffles without a discard date -An 8 oz to go coffee of cup in the freezer -1 unlabeled covered soup style bowl of apple sauce with a discard date of 2/21/2025 During a surveyor interview on 2/25/2025 at 9:52 AM with the FSD, he acknowledged the above observations, and he indicated that he was unaware of the facility's policy Use and Storage of Food Brought in by Visitors. 4. Record review of the Rhode Island Food Code, 2018 Edition, section 4-601.1 1 states in part, .(A) equipment food contact surfaces .shall be clean to sight .(B) The FOOD CONTACT SURFACES of cooking EQUIPMENT .shall be kept free of encrusted grease deposits and other soil accumulations. (C) NON-FOOD CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris . During the initial tour of the main kitchen and 1st floor kitchenette on 2/24/2025 at 8:20 AM, the following was observed: -The microwave had an accumulation of a black matter splattered on the inside of the glass door, above the cooking area, and on the glass turn plate -The hoses connecting the bag-in-box juice dispensing system that is used for residents to dispense apple juice, cranberry juice, orange juice, a diet beverage with lemon flavor, and strawberry kiwi beverages were observed to have an accumulation of a dried, sticky substance on the connection pieces, hoses, and on the shelf where the boxes were resting -2 unlabeled large storage bins approximately 27 gallons in size, both more than half full containing a white powdered substance, visibly dirty with an accumulation of residue on the outside of the bins -The microwave on first floor kitchenette was observed with an accumulation of light brown matter on the inside of the glass door, above the cooking areas and on the glass turn plate During a subsequent surveyor interview with the FSD following the above observations, he acknowledged the observations and indicated that the dietary staff were responsible for the cleanliness of the kitchen and kitchenettes. However, he was unable to provide evidence that routine cleaning and maintenance was performed. Cross Reference 804

46118 46241 46539 48928 50004 Based on 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 2 of 2 residents reviewed for dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to.), Resident ID #s 35 and 137, 1 of 2 residents reviewed for elopement, Resident ID #161, 1 of 2 residents reviewed for wounds infected with a Multidrug Resistant Organism (MDRO), Resident ID #83 and 1 of 2 closed records reviewed, Resident ID #169. Findings are as follows: 1. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual last revised in October 2024 states in part, .Code peritoneal or renal dialysis which occurs at the nursing home or at another facility . 1a. Record review revealed Resident ID #35 was admitted to the facility in July 2018 with a diagnosis including, but not limited to, diabetes mellitus. Review of a Minimum Data Set (MDS) assessment dated [DATE], Section O, titled, Special Treatments, Procedures, and Programs revealed the resident was checked off for receiving dialysis while a resident during the 7-day look-back period. Record review failed to reveal evidence that Resident ID #35 was receiving dialysis treatments. 1b. Record review revealed Resident ID #137 was readmitted to the facility in October 2024 with diagnoses including, but not limited to, dependence on renal dialysis and end stage renal disease. Record review of a care plan last revised 5/20/2024 revealed that Resident ID #137 requires dialysis related to renal failure. Review of a physician's order dated 10/17/2024 revealed that Resident ID #137 receives dialysis 3 days per week. Review of a MDS assessment dated [DATE], Section O, titled, Special Treatments, Procedures, and Programs revealed the resident was not checked off for dialysis while a resident during the 7-day look-back period. 2. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual last revised in October 2024 states in part, Identify all alarms that were used at any time (day or night) during the 7-day look-back period, code the frequency of use: Code 0, not used: if the device was not used during the 7-day look-back period. Code 1 used less than daily .Code 2, used daily .Wander/elopement alarm includes devices such as bracelets [wander guard] .that activate an alarm and/or alert the staff when the resident nears or exits . Record review revealed Resident ID #161 was admitted to the facility in October 2024 with a diagnosis including, but not limited to, dementia. Record review revealed the following physician's orders: -10/30/2024 Check wander guard functionality every night for safety. -10/30/2024 Check wander guard placement location-left wrist every shift. -1/27/2025 Wander guard expires 2/24/2026. Record review of the January and February 2025 Medication Administration Report revealed the above orders were signed off as completed daily from 1/30/2025 through 2/5/2025. Review of a MDS assessment dated [DATE], Section P, titled, Alarms revealed the resident was not coded for the use of a wander guard during the 7-day look-back period. 3. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual last revised in October 2024 states in part, Code diseases that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period . Record review revealed Resident ID #83 was admitted to the facility in December of 2023 with a diagnosis including, but not limited to, methicillin-resistant Staphylococcus aureus (MRSA is a MDRO that causes infections in different parts of the body). Record review revealed that Resident ID #83 tested positive for MRSA in his/her leg wound on 3/4/2024. Record review revealed that Resident ID #83's leg wound tested positive again for MRSA in November of 2024. Review of a MDS assessment dated [DATE], Section I, titled, Active Diagnoses in the Last 7 Days revealed the resident was not coded for having an active diagnosis of an MDRO. 4. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual last revised in October 2024 states in part, Review the medical record including the discharge plan and discharge orders for documentation of discharge location . Record review revealed Resident ID #169 was admitted to the facility in January of 2025 with diagnoses including, but not limited to, status post fall and pain. Record review of a nursing progress note dated 1/27/2025 revealed that Resident ID #169 was discharged home with services on 1/27/2025. Review of a MDS assessment dated [DATE], Section A, titled, Discharge Status revealed the resident was coded for a planned discharge to the hospital. During a surveyor interview on 2/27/2025 at 11:04 AM, with the MDS Coordinator, she revealed that the MDS assessments for Resident ID #s 35, 83, 137, 161 and 169 were coded in error and would be modified with the correct information after being brought to the facility's attention by the surveyor. During a surveyor interview on 2/27/2025 at 2:42 PM, with the Administrator, she acknowledged that the above MDS assessments for Resident ID #s 35, 83, 137, 161 and 169 were coded inaccurately.

Based on record review and staff interview, it has been determined that the facility failed to review and revise the resident's care plan by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments relative to 29 of 29 long term care residents reviewed, Resident ID #s, 3, 5, 6, 9, 10, 15, 21, 22, 23, 25, 29, 35, 38, 44, 67, 70, 75, 78, 83, 88, 95, 123, 129, 137, 139, 140, 142, 161, and 520. Findings are as follows: 1. Record review revealed Resident ID #3 was originally admitted to the facility in May of 2024 with diagnoses including, but not limited to, diabetes mellitus type 2 and chronic heart failure. Record review revealed the most recent Quarterly Minimum Data Set (MDS) Assessment was completed on 12/17/2024. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment. 2. Record review revealed Resident ID #5 was originally admitted to the facility in September of 2025 with diagnoses including, but not limited to, diabetes mellitus type 2 and chronic pain. Record review revealed the most recent Quarterly MDS Assessment was completed on 1/17/2025. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment. 3. Record review revealed Resident ID #6 was originally admitted to the facility in December of 2022 with diagnoses including, but not limited to, anxiety disorder and high blood pressure. Record review revealed the most recent Quarterly MDS Assessment was completed on 1/25/2025. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment. 4. Record review revealed Resident ID #9 was admitted to the facility in February of 2011 with diagnoses including, but not limited to, epilepsy and dementia. Record review revealed the most recent Quarterly MDS Assessment was completed on 12/14/2024. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment. 5. Record review revealed Resident ID #10 was admitted to the facility in June of 2021 with diagnoses including, but not limited to, repeated falls and pulmonary infection. Record review revealed the most recent Quarterly MDS Assessment was completed on 12/23/2024. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment. 6. Record review revealed Resident ID #15 was originally admitted to the facility in November of 2019 with diagnoses including, but not limited to, diabetes mellitus type 2 and muscle weakness. Record review revealed the most recent Quarterly MDS Assessment was completed on 12/18/2024. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment. 7. Record review revealed Resident ID #21 was originally admitted to the facility in February of 2022 with diagnoses including, but not limited to, heart failure and acute respiratory failure. Record review revealed the most recent Quarterly MDS Assessment was completed on 12/26/2024. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment. 8. Record review revealed Resident ID #22 was originally admitted to the facility in February of 2024 with diagnoses including, but not limited to, dementia and acute respiratory failure. Record review revealed the most recent Comprehensive MDS Assessment was completed on 12/16/2024. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the comprehensive assessment. 9. Record review revealed Resident ID #23 was originally admitted to the facility in July of 2024 with diagnoses including, but not limited to, seizures and dementia. Record review revealed the most recent Quarterly MDS Assessment was completed on 2/5/2025. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment. 10. Record review revealed Resident ID #25 was readmitted to the facility in June of 2024 with diagnoses including, but not limited to, seizures and a history of falling. Record review revealed the most recent Quarterly MDS Assessment was completed on 2/3/2025. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment. 11. Record review revealed Resident ID #29 was originally admitted to the facility in March of 2021 with diagnoses including, but not limited to, kidney failure and dementia. Record review revealed the most recent Comprehensive MDS Assessment was completed on 1/14/2025. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the comprehensive assessment. 12. Record review revealed Resident ID #35 was originally admitted to the facility in July of 2018 with diagnoses including, but not limited to, diabetes mellitus type 2 and epilepsy. Record review revealed the most recent Quarterly MDS Assessment was completed on 1/29/2025. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment. 13. Record review revealed Resident ID #38 was originally admitted to the facility in April of 2023 with diagnoses including, but not limited to, diabetes mellitus type 2 and end stage renal disease (kidney disease). Record review revealed the most recent Quarterly MDS Assessment was completed on 12/9/2024. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment. 14. Record review revealed Resident ID #44 was originally admitted to the facility in December of 2020 with diagnoses including, but not limited to, diabetes mellitus and chronic obstructive pulmonary disorder (COPD). Record review revealed the most recent Quarterly MDS Assessment was completed on 1/22/2025. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment. 15. Record review revealed Resident ID #67 was admitted to the facility in September of 2023 with diagnoses including, but not limited to, seizures and dementia. Record review revealed the most recent quarterly MDS Assessment was completed on 12/25/2025. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment. 16. Record review revealed Resident ID #70 was originally admitted to the facility in November of 2023 with diagnoses including, but not limited to, COPD and muscle weakness. Record review revealed the most recent Quarterly MDS Assessment was completed on 2/1/2025. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment. 17. Record review revealed Resident ID #75 was originally admitted to the facility in February of 2022 with diagnoses including, but not limited to, epilepsy and acute kidney failure. Record review revealed the most recent Quarterly MDS Assessment was completed on 1/17/2025. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment. 18. Record review revealed Resident ID #78 was originally admitted to the facility in July of 2022 with diagnoses including, but not limited to, diabetes mellitus type 2 and seizures. Record review revealed the most recent Quarterly MDS Assessment was completed on 1/1/2025. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment. 19. Record review revealed Resident ID #83 was originally admitted to the facility in December of 2023 with diagnoses including, but not limited to, acute kidney failure and difficulty walking. Record review revealed the most recent Comprehensive MDS Assessment was completed on 12/23/2024. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the comprehensive assessment. 20. Record review revealed Resident ID #88 was originally admitted to the facility in September of 2023 with diagnoses including, but not limited to, chronic kidney disease and post-traumatic stress disorder. Record review revealed the most recent Quarterly MDS Assessment was completed on 12/17/2024. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment. 21. Record review revealed Resident ID # 95 was originally admitted to the facility in July of 2020 with diagnoses including, but not limited to, COPD and mood disorder. Record review revealed the most recent Quarterly MDS Assessment was completed on 2/5/2025. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment. 22. Record review revealed Resident ID #123 was originally admitted to the facility in December of 2022 with diagnoses including, but not limited to, diabetes mellitus type 2 and dementia. Record review revealed the most recent Quarterly MDS Assessment was completed on 2/19/2025. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment. 23. Record review revealed Resident ID #129 was originally admitted to the facility in October of 2022 with diagnoses including, but not limited to, dementia and muscle weakness. Record review revealed the most recent Quarterly MDS Assessment was completed on 12/24/2024. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment. 24. Record review revealed Resident ID #137 was originally admitted to the facility in July of 2024 with diagnoses including, but not limited to, end stage renal disease (kidney disease) and altered mental status. Record review revealed the most recent Quarterly MDS Assessment was completed on 2/3/2025. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment. 25. Record review revealed Resident ID #139 was originally admitted to the facility in September of 2023 with diagnoses including, but not limited to, repeated falls and pulmonary infection. Record review revealed the most recent Quarterly MDS Assessment was completed on 1/17/2025. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment. 26. Record review revealed Resident ID #140 was admitted to the facility in October of 2023 with diagnoses including, but not limited to, dementia and COPD. Record review revealed the most recent Quarterly MDS Assessment was completed on 1/10/2025. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment. 27. Record review revealed Resident ID #142 was admitted to the facility in July of 2024 with diagnoses including, but not limited to, dementia and protein-calorie malnutrition. Record review revealed the most recent Quarterly MDS Assessment was completed on 1/29/2025. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment. 28. Record review revealed Resident ID #161 was admitted to the facility in October of 2024 with a diagnosis including, but not limited to, dementia. Record review revealed the most recent Quarterly MDS Assessment was completed on 2/5/2025. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the quarterly assessment. During a surveyor interview on 2/25/2025 at 8:19 AM, with Resident ID #161's family member, when asked by the surveyor if s/he attended the resident's care plan meetings, s/he revealed that s/he did not know what a care plan meeting was and indicated that s/he has never attended one. 29. Record review revealed Resident ID #520 was originally admitted to the facility in March of 2020 with diagnoses including, but not limited to, acute and chronic respiratory failure. Record review revealed the most recent Comprehensive MDS Assessment was completed on 1/19/2025. Record review failed to reveal evidence that the resident's care plan was reviewed and revised by the interdisciplinary team following the comprehensive assessment. During a surveyor interview with multiple residents, during the Resident Council task on 2/25/2025 at approximately 1:05 PM, they indicated that they were not typically involved in care plan meetings. During a surveyor interview on 2/27/2025 at 12:46 PM with MDS Nurse, Staff B, she indicated that care plan meetings are held quarterly to review and revise the care plans for every resident and that documentation of the meetings are kept in a binder or documented in the resident's progress notes. She indicated that a physician isn't typically included in the care plan meetings. Furthermore, she indicated that sometimes she needs to work on the floor and doesn't have time to hold the care plan meetings, as required. During a surveyor interview on 2/27/2025 at 1:03 PM with the Director of Nursing Services and the Administrator, they indicated that care plan meetings should be held quarterly. They further indicated that the Nursing Assistant's and the physicians aren't typically included in care plan meetings. Additionally, they could not provide evidence that the above mentioned residents' care plans were reviewed and revised, as required, by interdisciplinary team. 46241 46539 48928

Based on record review and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of practice for 1 of 1 resident reviewed relative to Narcan administration, Resident ID #25, 2 of 6 residents reviewed for following physician orders relative to unnecessary medication, Resident ID #s 44 and 123, 1 of 1 resident seen by the podiatrist, Resident ID #78, 1 of 2 residents observed with a non-pressure wound, Resident ID #83 and 1 of 3 residents receiving a medication that requires blood levels to be monitored, Resident ID #95. Findings are as follows: 1. According to the facility policy titled Narcan Administration, states in part, .Policy: Narcan administration is for the occurrence of an opioid overdose. An opioid overdose is an acute condition in the case of excessive opioid use. Narcan should be administered in emergency cases of overdose . PROCEDURE: 1. An assessment for substance use disorder (SUD) will be done upon admission for each resident . 2. Consideration of a clinical overdose could include: use of opioids, known history of substance use disorder, slow or no breathing, gurgling, gasping or snoring, cool/clammy skin, cyanosis [bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation] . 4. Attempt to verbally arouse the resident. Use a sternal rub if the resident is unconscious and is to be used prior to determining an opioid overdose . 7. Clinical Overdose is classified as having -a respiratory rate of 8-10 or lower per minute -inability to arouse/unconscious-pinpoint pupils . 9. If a resident meets criteria of clinical overdose, ensure there are 2 staff members present through the administration of Narcan 10. Procedure for initiating Narcan administration: -Call 911 and report possible overdose with plan to administer Narcan & retrieve crash/emergency cart . -Stay with resident until rescue arrives . Record review revealed Resident ID #25 was readmitted to the facility in June of 2024 with diagnoses including, but not limited to, seizures and muscle weakness. Record review revealed a nursing progress note dated 2/15/2025 indicating that the resident was noted with slurred speech, dilated pupils and leaning forward with his/her head down. The resident's vital signs were as follows; blood pressure 126/73 (normal range 100/65 to 120/80), heart rate 68 (normal range 60-100), respirations 16 (normal range 12-20), temperature 97.8 (normal range 97-99), pulse oximetry (blood oxygen level) was 94% (normal range 95-100%) on room air, and the blood sugar was 156 (normal level between 70-100). Upon further assessment, the resident had difficulty staying awake and was coughing with liquids. The on call provider was notified and orders were received to obtain blood work, a urine specimen, and to administer Narcan 0.4 milligram (mg) intranasally for a one time administration. Further review revealed the Narcan was administered, as ordered. Record review failed to reveal evidence that an SUD Assessment was completed upon admission, per the facility policy. Further record review failed to reveal evidence that the resident had an order for an opioid medication. During a surveyor interview on 3/3/2025 at 11:30 AM with Licensed Practical Nurse (LPN), Staff C, she was unable to provide evidence that an SUD Assessment was completed for the resident. Additionally, she acknowledged that the resident's clinical presentation on 2/15/2025, was not indicative of a narcotic overdose, per the facility policy. During a surveyor interview on 3/3/2025 at 11:46 AM with LPN, Staff D, she revealed that when she went to administer the resident his/her medications on 2/15/2025, the resident was lethargic but arousable. She further revealed that she contacted the on-call provider, reviewed the resident's medications and the provider ordered lab work, diagnostic testing and Narcan. Staff D revealed she also performed a sternal rub and that the resident would awaken but then become lethargic again. Staff D revealed she was not familiar with the Narcan policy and after reviewing the policy with the surveyor, Staff D acknowledged that the resident's pupils were not pinpoint, rather very dilated, s/he was arousable at times and his/her vital signs were normal. Additionally, Staff D revealed she did not call 911 per the facility policy. During a surveyor interview on 3/3/2025 at 11:43 AM with the Administrator, she was unable to provide evidence that the facility policy was followed related to a SUDs Assessment, the assessment of a resident to meet the criteria of an overdose, and to call 911 prior to the administration of Narcan. 2a. 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 Resident ID #44 was admitted to the facility in December of 2020 with a diagnosis including, but not limited to, ocular hypertension (a condition where the pressure in the eye is higher than normal). Record review revealed a physician's order dated 11/11/2021 for Latanoprost Solution 0.005 % (a medication prescribed to reduction the fluid pressure inside the eye) eye drops, instill 1 drop in both eyes at bedtime. During a surveyor interview and simultaneous observation with the resident in his/her room on 2/27/2025 at 9:24 AM, s/he revealed that s/he has not been receiving his/her Latanoprost eye drops at bedtime. S/he further revealed that the eye drops are left at his/her bedside for him/her to administer, but they have not been available for approximately two to four weeks. Additionally, s/he revealed that s/he has been told by staff that they have been waiting for the pharmacy to deliver the eye drops. Surveyor observation of the resident's room failed to reveal evidence of the Latanoprost eye drops. Record review revealed a completed Self-Administer Screening document, dated 4/28/2023 for the Latanoprost eye drops. Further review of the document indicates the resident is completely safe to administer the medication and that the eye drops can be left at his/her bedside. Record review of the February 2025 Medication Administration Record (MAR) from 2/1/2025 through 2/27/2025 revealed the Latanoprost eye drops were signed off as administered. During a surveyor interview and simultaneous observation on 2/27/2025 at 9:50 AM with Registered Nurse, Staff E, she acknowledged that the Latanoprost eye drops were signed off as administered and according to the MAR documentation, the eye drops were last ordered from the pharmacy on 12/25/2024. During the interview with Staff E, she was unable to locate the Latanoprost eye drops. During a surveyor interview on 2/27/2025 at approximately 9:55 AM with Medication Aide, Staff F, he acknowledged that the Latanoprost eye drops were not in the medication cart and that they are kept at the resident's bedside for him/her to administer. During a subsequent interview on 2/27/2025 at approximately 10:00 AM with Staff E, she placed a call to the pharmacy in the presence of the surveyor, to inquire about the eye drops. Staff E was told by the pharmacist that the eye drops were last ordered on 12/25/2025 and that they were never re-ordered. During a surveyor interview on 2/27/2025 at 11:39 AM with the Director of Nursing Services (DNS), she revealed that she would have expected the nurse to call the pharmacy to ensure the delivery of the medication. Additionally, she could not provide evidence that the Latanoprost eye drops were administered, as ordered, from 2/1/2025 through 2/27/2025. 2b. Record review revealed Resident ID #78 was readmitted to the facility in December of 2024 with diagnoses including, but not limited to, diabetes mellitus and a right hallux (great toe) infection. Record review revealed the resident was evaluated by the podiatrist on 2/24/2025 and recommendations were made for a treatment to cleanse the wound with Betadine (an antiseptic solution used for skin disinfection) and to apply triple antibiotic ointment, twice daily for 10 days, then leave it open to air. Record review of a nursing progress note dated 2/24/2025 revealed the resident's provider was notified and in agreement with the podiatrist's treatment recommendations. Record review of the physician's orders failed to reveal evidence that the above podiatrist's recommendations were implemented. During a surveyor interview on 3/3/2025 at 8:51 AM with Registered Nurse, Staff G, she acknowledged that the podiatrist's recommendations had not been implemented. During a surveyor interview on 3/3/2025 at 9:02 AM with the DNS, she acknowledged that the podiatrist's recommendations were not implemented for the resident's wound, as ordered. 2c. Review of a facility policy titled, Clean Dressing Technique dated January of 2018 states in part, .It is the policy of this facility to prevent the spread of infection by utilizing proper dressing change techniques .Check the physician order for current, correct treatment .Open supplies onto the clean field .Remove gloves. Wash hands. (Hand sanitizer may be used) Apply clean gloves .using the no touch technique i.e., do not directly touch any item that will come in contact with the wound .Apply any medication ordered and dress wound. Remove gloves and wash hands . Record review revealed Resident ID #83 was originally admitted to the facility in December of 2023 with diagnoses including, but not limited to, chronic venous hypertension with an ulcer (a condition characterized by elevated venous pressure, which leads to vein dilation, skin changes, and wounds) and a Methicillan Resistant Staphylococcus Aureus (multidrug resistant bacteria). Record review of the physician's orders revealed a treatment order dated 2/13/2025 to cleanse the wound with Vashe Solution (wound cleanser to clean, irrigate, and remove infected or damaged tissue), apply A&D ointment around the wound, then apply Adaptic (a nonadherent petrolatum gauze that is applied in the base of the wound bed) followed by blue foam moistened with normal saline, cover with an absorbent pad, wrap with gauze roll, and then wrap with ACE bandages. During a surveyor observation of a wound dressing change on 2/27/2025 at 10:03 AM with LPN, Staff H, revealed she failed to perform hand hygiene between glove changes and used a gloved finger to apply the A & D ointment rather than an applicator. Additionally, she failed to cut the Adaptic gauze to the size of the wound bed and failed to apply the ace bandages, as ordered. During a surveyor interview on 2/27/2025 at 10:44 AM and at 11:26 AM with Staff H, she acknowledged that she failed to perform hand hygiene between glove changes, did not cut the Adaptic gauze, and used her gloved hand to apply the ointment as she left the applicator on the cart. Additionally, she acknowledged that she had forgotten to apply the resident's ace bandages. 2d. Record review revealed Resident ID #123 was admitted to the facility in December of 2022 with a diagnosis including, but not limited to, high cholesterol. Record review revealed the resident had blood work obtained for a lipid panel (various levels of fats in the blood including cholesterol and triglyceride levels). Record review of a provider progress note dated 2/7/2025 authored by the Nurse Practitioner (NP), Staff I, indicated the resident has slightly elevated cholesterol levels and she indicated in her plan to implement a low dose of Atorvastatin 20 mg, every night, at hour of sleep. Record review of the physician's orders failed to reveal evidence of an order for Atorvastatin. During a surveyor interview on 3/3/2025 at 11:21 AM with LPN, Staff J, he acknowledged that the resident does not have an order for Atorvastatin. During a surveyor interview on 3/3/2025 at 11:24 AM with NP, Staff I, she acknowledged that she ordered for the resident to receive Atorvastatin 20 mg, at hour of sleep. 3. According to Mosby's Fundamentals of Nursing Concepts, Process and Practice, 4th Edition, on page 809, .A Registered Nurse checks all transcribed orders against the original order for accuracy and thoroughness. Record review revealed Resident ID #123 was admitted to the facility in December of 2022 with a diagnosis including, but not limited to, conditions of the skin. Record review revealed a physician's order dated 2/18/2025 for Triamcinolone Acetonide cream (a topical cream prescribed to treat skin conditions) 0.025 %, apply to rashes topically, two times a day, for rashes. Further review of the order failed to reveal evidence of a location indicated for the cream to be applied. During a surveyor observation and simultaneous interview on 2/27/2025 at 10:57 AM with LPN, Staff B, she revealed that she was not certain where the Triamcinolone cream was to be applied. Staff B further revealed that the resident's previous cream order was for the top of the resident's feet and back of legs. During an observation of the resident's feet and their legs, no rash wash observed. Additionally, Staff B acknowledged that the Triamcinolone order did not indicate a location for where the cream is to be applied. During a surveyor interview on 2/27/2025 at 11:47 AM with the DNS, she revealed that she would have expected the Triamcinolone order to include a location for the treatment and she acknowledged that it did not. 4. According to Lippincott Nursing Procedures, 9th edition, states in part, .Anticipate monitoring for therapeutic levels of any antiseizure medications that the patient is taking . Record review revealed Resident ID #95 was initially admitted to the facility in August of 2020 with diagnoses including, but not limited to, major depressive disorder, psychotic disturbance, mood disturbance, and convulsions (involuntary, rhythmic muscle contractions that can be a symptom of seizures). Record review of the physician's orders revealed the resident has been receiving Valproic Acid (a medication prescribed to treat seizures and certain behavioral disorders), delayed release 250 mg, twice daily, since 4/21/2024. Record review failed to reveal evidence that a Valproic Acid level was obtained by the facility and monitored. During a surveyor interview on 2/28/2025 at 3:08 PM with LPN, Staff C, she was unable to provide evidence that a Valproic Acid level had been obtained. Record review of a nursing progress note dated 3/3/2025 at 10:05 AM, authored by Staff C, revealed that she had contacted the resident's provider relative to there not being a Valproic Acid level and that the provider ordered a Valproic Acid level to be obtained every 6 months with routine lab work, after it was brought to the facility's attention by the surveyor. During a surveyor interview with the facility's Pharmacy Consultant on 3/3/2025 at 9:10 AM, she revealed that she would expect a Valproic Acid level to be ordered by the provider, every 6 months. An attempt was made to conduct a telephone interview on 3/3/2025 at 9:44 AM by the surveyor with the resident's physician and NP. A message was left for both providers, however no return call was received. 46118 48928

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident received adequate supervision for 1 of 1 resident reviewed who was assessed to be a moderate risk for wandering, previously displayed exit seeing behavior and was able to successfully elope from the facility, Resident ID #1. Findings are as follows: Record review of a facility policy titled Elopement dated 4/10/2018, states in part, .Elopement - leaving the facility without permission and/or notification to the facility .An assessment will be completed within 24-hours of admission. 1. A re-assessment will be completed for any resident who demonstrates any of the following: Verbalizing a desire to leave the building .exit seeking .A resident assesses to be at risk. The following actions may be employed: 1. Application of a wanderguard 2. Initiation of frequent checks 3. Initiate Care Plan 4. Room transfer to a secure area 5. Residents at risk for elopement identified to appropriate staff . Record review of a facility reported incident sent to the Rhode Island Department of Health on 11/12/2024, revealed that on 11/11/2024 Resident ID #1 left the building and was found in the parking lot next door. A neighbor called the police, and the resident was taken to the hospital for safety. Although during the complaint survey it was determined by record review and interview that the resident was located approximately 1.5 miles from the facility, found by a jogger. Emergency services were called and s/he was transported to the hospital. During a surveyor observation on 11/18/2024 at approximately 11:00 AM revealed the facility is equipped with a wander guard system. When a resident wearing bracelet attempts to leave the facility an alarm will go off alerting the staff. Record review revealed the resident was admitted to the facility in October of 2024 with a diagnosis including, but not limited to, dementia. Further review revealed that the resident resides on the facility's secured/locked unit. Review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 6 out of 15, indicating s/he has severely impaired cognition. Record review of a Wander Risk assessment dated [DATE] revealed the resident scored a 9, indicating s/he is a moderate risk for wandering behaviors. Record review of a nursing progress note dated 11/10/2024 at 12:37 PM states in part, Resident with some agitation this shift .Asks why we are keeping [him/her] here. Trying to get on the elevator x2. Redirected with difficulty. Record review failed to reveal evidence that a Wander Risk Assessment was completed after the resident displayed exit seeking behaviors, that a wanderguard was placed on the resident or that the resident was placed on frequent checks per the facility policy. Additionally, the care plan was not updated with interventions to mitigate the resident's exit seeking behavior following the incident on 11/10/2024. Record review of facility investigation statements for the 11/11/2024 incident indicated that staff last recall seeing the resident between 4:45 PM and 5:15 PM, eating dinner, but no one witnessed the resident exit the facility. Record review of a progress note authored by Registered Nurse, Staff A, on 11/11/2024 at 9:40 PM, revealed that the last time staff saw the resident on the evening of 11/11/2024, prior to his/her elopement was at approximately 5:15 PM, when s/he was observed sitting in the dayroom eating dinner. At approximately 6:58 PM the facility received a phone call from the hospital indicating that the resident was in the emergency room . Additionally, two staff members from the facility went to the hospital to pick up the resident and return him/her to the facility. Record review of hospital documentation titled ED [emergency department] Triage Note dated 11/11/2024, revealed that the resident was brought in by emergency medical services, after a jogger called 911 and reported a Spanish speaking person who was confused about his/her location. The resident was assessed in the ED and was unsure of the date and where s/he was. The resident reported s/he was from [NAME] (a city located approximately 20 miles away from the facility) and lived at a local school. Additionally, the document revealed that the secretary from the hospital called the facility to see if they were missing a resident. Per the report the facility sent staff to the hospital to identify and pick up the resident. The surveyor made two attempts to contact Staff A. Staff A failed to return any of these phone calls. During a surveyor interview on 11/18/2024 at 2:35 PM with the Administrator, she acknowledged that the facility was not aware that Resident ID #1 left the faciity on [DATE] until the hospital called to notify them. She further acknowledged that the staff were unaware how the resident made his/her way off of the secured unit and exited the facility. Additionally, the Administrator was unable to determine when the resident had left facility and how long s/he had been gone. The facility's failure to implement interventions for a resident who was identified on their admission assessment as a moderate risk for wandering and to follow their policy relative to wandering behaviors placed a cognitively impaired resident at risk for more than minimal harm, injury, impairment, or death. These failures resulted in this resident making his/her way off of the secured unit, exiting the facility unsupervised and being found by a jogger approximately 1.5 miles away from the facility.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 1 of 3 wound treatments observed, Resident ID #129. Findings are as follows: Record review of an undated facility policy titled, Wounds - Dressing Changes, states in part, .This policy and procedure intent is to ensure that .resident's skin integrity is addressed appropriately. Dressing changes will be done based on the physician orders using clean dressing change procedure .1. Upon discovery of a new skin integrity issue, the nurse will .Assess and measure the wound .The charge nurse will notify the physician, resident representative .and wound nurse .Order entered for treatment for wound .Nurse note written with a description of alteration in skin integrity, treatment initiated, and notification to the physician . Review of the facility policy, revised on 3/12/2022 titled, Skin Care Protocol, states in part, .For those residents identified as 'at risk' interventions must be carried out in a timely manner. Interventions to consider include but may not be limited to .Pressure-relieving .cushion .Repositioning .Minimize exposure to moisture; keep resident dry and clean . Record review revealed the resident was readmitted to the facility in February of 2024 with diagnoses including, but not limited to, pressure ulcer of the sacral region (tail bone area), stage 4 (severe type of pressure ulcer, the skin is severely damaged, and the surrounding tissue begins to die [necrosis] may extend to muscle and bone), muscle weakness, and dementia. Record review of a Minimum Data Set Assessment (MDS) dated [DATE], revealed a Brief Interview for Mental Status score of 0 out of 15, indicating severely impaired cognition. Additionally, s/he does not walk and is dependent on staff members for mobility which includes transferring from bed to chair. The MDS assessment further revealed that the resident was admitted to the facility with the stage 4 pressure area to his/her sacrum area. It is documented that the treatment included, but is not limited to, a .Pressure reducing device for chair . Additional record review revealed a care plan dated 1/15/2024, which indicates that the resident has a pressure ulcer to his/her sacrum area and has the potential for pressure ulcer development related to immobility. Interventions include, but are not limited to, follow the facility policies and protocols for the prevention and treatment of skin breakdown. Further review of the care plan did not identify any additional pressure areas. During a surveyor observation on 3/12/2024 at 11:11 AM, the following was revealed: - The resident was receiving assistance with transferring from his/her recliner chair to his/her bed with a mechanical lift and Nursing Assistant (NA), Staff G and by Staff H. - The resident was noted to be incontinent of loose stool. His/her adult incontinence brief was saturated with loose stool which extended out of the brief and continued to his/her back. - The sacrum wound was covered with a dressing which was also saturated with stool. - A white, soiled adhesive dressing was observed to his/her right lower buttocks area (ischium). - There was no cushion observed to his/her recliner chair. - A non-blanchable (discoloration of the skin that does not turn white when pressed) red/purple area was observed to his/her right hip and left lateral thigh. During a surveyor interview on 3/12/2024 at 11:20 AM, immediately following the above-mentioned observation with Staff G, she revealed that she was the NA assigned to provide care for Resident ID #129 during the 7:00 AM to 3:00 PM shift. She further revealed that when she arrived on shift at approximately 7:30 AM, the resident was already out of bed sitting in his/her recliner chair. Staff G indicated that she did not transfer the resident out of the recliner or provide him/her with incontinence care until the above-mentioned observation, indicating s/he sat in his/her recliner for approximately 4 hours. Record review revealed the following physician's orders relative to the resident's skin conditions: - 1/17/2024, Body check weekly every Wednesday evening - 2/15/2024, Off load wound; reposition as tolerated every shift - 2/23/2023, Coccyx [sacrum] wound to be cleansed with 1/4 strength Dakins (a solution used to treat or prevent wound infections) moisten kerlix (bandage) with Dakins and gently pack the wound, cover with island border gauze twice daily and as needed every day and evening shift. During a surveyor interview on 3/12/2024 at 11:36 AM with Licensed Practical Nurse, Staff L, she revealed that the resident was out of bed sitting in his/her recliner chair when she arrived on shift at approximately 7:30 AM. Additionally, she was unable to say if the non-blanchable areas noted to the resident's right hip and lateral left thigh were new. Furthermore, she was unable to explain why a dressing was in place to the resident's right ischium without a physician's order. Further record review failed to reveal evidence that the areas to Resident ID #129's right hip, left lateral thigh and right ischium existed prior to this observation. Furthermore, the record revealed that the weekly body check was conducted on 3/6/2024 on the Treatment Administration Record (TAR) , however, the record failed to reveal documentation of the findings. During a surveyor observation and simultaneous interview on 3/12/2024 at 12:20 PM with the Wound Physician and the facility's Wound Nurse/Infection Preventionist revealed the following: The wound physician revealed that he would expect that a pressure reducing device would be in place to Resident ID #129's chair. Additionally, he would expect staff to reposition the resident at least every 2 hours. He also acknowledged that the wounds to Resident ID #129's right hip, left lateral thigh, and right ischium were new. Further record review failed to reveal evidence that the physician was notified of the wound to the resident's right ischium. During a surveyor interview on 3/14/2024 at 9:20 AM, with Registered Nurse (RN), Staff B, she revealed that she found the wound to the resident's right ischium on 3/11/2024. Staff B acknowledged that she did not document the wound description or obtain measurements of the wound. Furthermore, she revealed that she failed to notify the physician and obtain treatment orders prior to applying a treatment to the resident's right ischium wound. During surveyor interviews on 3/12/2024 at 1:12 PM and 3/14/2024 at 11:12 AM with the Director of Nursing Services, she revealed that she would expect staff to protect the resident's skin and check him/her at least every half to one hour and report any new areas to the physician and the resident's family. She also indicated that she would expect documentation of a weekly body check findings to be in the progress notes as well as signed off on the (TAR). Furthermore, she revealed that she was the assigned nurse for Resident ID #129 on 3/6/2024 during the 3:00 PM - 11:00 PM shift and revealed that she documented his/her weekly body check findings as a late entry on 3/13/2024, after it was brought to her attention by the surveyor.

46715 Based on record review and staff interview, it has been determined that the facility failed to ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 2 of 11 residents reviewed for nutrition, Resident ID #s 98 and 129. Findings are as follows: Review of a facility policy titled, Weight Monitoring Policy dated 2/24/2017, states in part, .All residents are to be weighed on a monthly basis between the first and the sixth of the month .If the weight is +/- [greater than/less than] 3 pounds from the previous weekly weight or +/- 5% on a monthly the resident is to be removed from the scale and reweighed (this needs to be done no later than within 24 hours for the questionable weight) .The dietician will review the weights and determine if additional intervention may need to be added . 1. Record review revealed that Resident ID #98 was readmitted to the facility in February of 2024 with diagnoses of, but not limited to, mild neurocognitive disorder and acute kidney failure. Review of the Weights and Vitals Summary Report revealed the following weights: 2/6/2024 - 136.2 pounds (lbs) 2/27/2024 - 128.6 lbs Review of the progress notes revealed the Dietician made the following recommendations on 2/28/2024: Notify the doctor of weight loss and poor appetite, question using an appetite stimulant, add 8-ounce house supplement two times per day. Record review failed to reveal evidence that an appetite stimulant or a house supplement was initiated per the dietician's recommendations. Further review of the resident's recorded weights revealed a weight on 3/12/2024 of 125 lbs, indicating the resident experienced an additional 3.6 lb weight loss in the 14 days following the dietician's recommendations that were never implemented. During a surveyor interview on 3/13/2024 at 8:20 AM with the Registered Dietician, she acknowledged that neither the appetite stimulant or the house supplement had been initiated for the resident. Additionally, she acknowledged the resident continued to lose weight. During a surveyor interview on 3/13/2024 at 10:08 AM via telephone with Nurse Practitioner, Staff N, she revealed that she was never made aware of the dietician's recommendations. Additionally, she revealed that she would have ordered both an appetite stimulant and a supplement for the resident if she had been made aware. During a surveyor interview on 3/13/2024 at approximately 2:00 PM with the Director of Nursing Services (DNS) she revealed that she would expect the staff to report the Dieticians recommendations to the provider and obtain orders. 2. Review of a facility provided document titled, March 2024 Monthly Weights states, reweigh all residents with a 3 pound difference immediately. Weight due by the 6th of each month. Record review revealed that Resident ID #129 was readmitted to the facility in February of 2024 with diagnoses including, but not limited to, dementia and atrial fibrillation (abnormal heart rate). Record review revealed the resident's weight was 169 lbs on 2/11/2024. Review of the March 2024 Monthly Weights revealed the resident's weight was 188.4 lbs. A weight gain of 19.4 lbs or 11.8%. Record review failed to reveal evidence of a re-weight per the facility policy. Further review failed to reveal evidence that the resident's provider or dietician were notified of his/her weight gain per the facility policy. Review of an Admission Minimum Data Set assessment dated [DATE] revealed that the resident is at nutritional risk and would require a nutrition care plan. Record review failed to reveal evidence that a care plan was initiated for the resident to address his/her nutritional risk. During a surveyor interview on 3/13/2024 at 9:35 AM with the Registered Dietician she acknowledged that a nutritional care plan was not initiated to address the resident's nutrition risk. Additionally, she was unaware of the residents 19.4 lb weight gain since the previous month. During a surveyor interview on 3/13/2024 at 2:09 PM with the DNS, she was unable to provide evidence of a reweight or notification to the physician and dietician of the weight gain per the policy. Additionally, she was unable to provide evidence that the facility ensured that residents maintain acceptable parameters of nutritional status for the above-mentioned residents.

Based on surveyor observation, record review, 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 1 of 3 wound treatments observed, Resident ID #79. Findings are as follows: According to the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities last revised on 2/3/2023 states in part, .Because pain can significantly affect a person's well-being, it is important that the facility recognize and address pain promptly. The facility's evaluation of the resident at admission and during ongoing assessments helps identify the resident who is experiencing pain or for whom pain may be anticipated during specific procedures, care, or treatment . Record review revealed the resident was readmitted to the facility in March of 2024 with diagnoses including, but not limited to, sepsis (an infection in the blood stream) and epilepsy. Review of a document titled, WOUND EVALUATION & MANAGEMENT SUMMARY dated 3/12/2024, revealed the resident has a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) to his/her sacrum (base of the spine) measuring 5 centimeters (cm) by 1.9 cm by 1 cm. Further review revealed a recommendation to administer pain medication prior to wound care. During a surveyor observation on 3/13/2024 at approximately 9:16 AM, revealed Licensed Practical Nurse, Staff M, performing wound care of the resident's stage 4 pressure ulcer. Throughout the duration of the wound treatment, the resident was noted to be yelling, swearing, and complaining of pain. Further, the nurse proceeded with the wound treatment and did not stop until the treatment was completed. During a surveyor interview on 3/13/2024 at 9:18 AM, with Staff M, she revealed that the resident does not have any pain medication available and further indicated that the resident is only in pain during wound treatments. During a subsequent interview on 3/13/2024 at 9:21 AM, with Staff M, she acknowledged the resident did not receive any pain medication prior to the observed wound treatment. She further revealed that she does not medicate the resident before wound treatments. Record review revealed a physician's order dated 6/14/2023 for Acetaminophen tablet, 650 milligrams, every six hours, as needed for temperature and pain. Review of the March 2024 Medication Administration Record failed to reveal evidence that the above pain medication was administered to the resident on 3/13/2024, prior to his/her wound treatment. During a surveyor interview on 3/13/2024 at 1:59 PM, with the Director of Nursing Services, she indicated that she would expect the resident to be medicated for pain prior to wound treatments. She further revealed that she would have expected the nurse to stop the wound treatment and administer the resident pain medication. 46715

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide adequate supervision to prevent an accident hazard for 1 of 2 residents reviewed for elopement, Resident ID #1. Findings are as follows: Record review of a facility reported incident sent to the Rhode Island Department of Health on [DATE] stated in part, Resident was noted to be missing from unit .Resident found by staff on nearby street. Review of a facility policy titled, Elopement, states in part, It is the intent of this policy to ensure the resident's right to a safe and secure environment . Review of an additional facility policy titled ELOPEMENT POLICY CODE PURPLE, states in part, It is the policy of [NAME] Health and Rehabilitation Center to prevent elopement of residents, particularly with Dementia . Review of the resident's record revealed s/he was admitted to the facility in February of 2023 with diagnoses including, but not limited to, unspecified dementia, major depressive disorder, and diabetes mellitus. Record review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 0 out of 15, indicating s/he has severe cognitive impairment. Further review of the MDS revealed s/he requires supervision secondary to his/her wandering behavior. Review of the resident's care plan revealed s/he was identified as an elopement risk/wanderer, and that s/he wears a Wanderguard bracelet on his/her wrist. Further review of the resident's progress notes revealed a Health Status note dated [DATE] indicated that the low side fire door was alarming and that the resident was found outside the building and s/he was placed on 15 minute checks. Additionally, a Health Status note dated [DATE] indicated that the resident took the elevator along with another residents' visitor and s/he was located on the 1st floor. Record review of an incident note dated [DATE] at 9:46 PM, authored by Registered Nurse, Staff A, revealed that the activity aide approached her after an attempt was made to deliver the resident's supper tray at 5:10 PM, and that the resident was not in his/her room. The note indicated that the entire facility was searched and that 911 was called after 5 minutes when the resident was not found. This incident note further indicated that the resident was picked up by the Assistant Director of Nursing (ADON) who located the resident, a few streets away from the facility. The resident was found to be wearing multiple layers of clothing. Review of AccuWeather for Woonsocket, Rhode Island revealed that on the day the resident went missing, the high temperature on [DATE] was 36 degrees Fahrenheit (F) with a low of 21 degrees F. During a surveyor interview with Certified Medication Technician, Staff B, on [DATE] at approximately noon, she indicated that she saw the resident last at 4:00 PM when the resident was administered medication. During a surveyor interview with the Administrator on [DATE] at 11:50 AM, she indicated that she's presently working on her investigation because it has not been determined how this resident was able to exit the facility from a locked unit. She further indicated that it was believed that the resident snuck on the elevator with another resident's family. During a surveyor interview with Staff A on [DATE] at 12:45 PM, she revealed that a Code Purple (resident elopement) was initiated and that the resident was returned by the ADON shortly before 6:00 PM. During a surveyor interview with the Receptionist, Staff C, on [DATE] at approximately 2:00 PM, she revealed that she was at the reception desk on [DATE]. When the resident was returned, the receptionist recognized the resident's clothing and his/her large bag. The receptionist believes she observed the resident coming out of the stairwell which is across from the reception desk before suppertime but that she was unable to identify him/her as a resident under all the clothes, and allowed him/her to exit via the front door of the facility. During surveyor interviews with the ADON on [DATE] and [DATE] at approximately 8:30 AM, she revealed that she checked both wanderguards to make sure they were properly functioning and that they were. She also revealed that she was able to get the resident into her car and safely back to the facility on the evening s/he eloped. She then revealed on [DATE] that she was concerned that the resident's multiple layers of clothing interfered with the wanderguard's capability but during our interview on [DATE], she was unable to determine this to be true. Additionally, the ADON revealed that the wanderguard alarm sounded when the resident was returned to the facility. During a surveyor interview with the Director of Maintenance on [DATE] at approximately 11:00 AM, he revealed that he observed footage from a camera by the 3rd floor elevator and nurse's station and indicated that there were three blind spots and they could not see if the resident had exited via the elevator or a fire door. He also determied that the wanderguard system was fully functioning, as were all the fire door exits, on [DATE], the day the resident eloped. During an exit interview on [DATE] with the Regional Administrator at approximately 1:00 PM, she was unable to provide evidence that this resident received adequate supervision. Due to the failure of the facility to provide adequate supervision to ensure a safe and secure environment, this resident eloped from a secured unit with a wanderguard in place and put his/her health and safety at risk. S/he was exposed to the cold, s/he could have been struck by a vehicle, and she could possibly have died .

Based on record review and staff interview, it has been determined that the facility failed to immediately consult with the physician when there is a significant change in the resident's physical status for 1 of 3 residents reviewed related to a significant weight gain, Resident ID #1. Findings are as follows: Record review revealed a community reported complaint dated 7/26/2023 alleging that Resident ID #1 was not permitted to return to the facility following a hospitalization due to his/her current weight. An investigation completed on 7/27/2023 revealed that the resident's weight had increased to a level where s/he was unable to be accommodated by the facility. Record review for the resident revealed s/he was originally admitted to the facility in March of 2023 with diagnoses including, but not limited to, lymphedema (localized swelling), morbid obesity, and chronic obstructive pulmonary disease. Record review of a physician order with a start date of 4/5/2023 revealed, OBTAIN WEEKLY WEIGHT TIMES 4 WEEKS every day shift every [Wednesday] for 4 Administrations until finished IF WEIGHT IS PLUS OR MINUS 3 POUNDS [lbs.] FROM PREVIOUS WEEK MUST RE-WEIGH IMMEDIATELY IF WEIGHT LOSS OR GAIN IS CORRECT NOTIFY MD AND SUPERVISOR, AND A PROGRESS NOTE MUST BE WRITTEN. Record review of the resident's weights revealed the following: - 553.2 lbs. on 3/30/2023 - 553 lbs. on 4/5/2023 - 553 lbs. on 4/8/2023 - 611 lbs. on 4/12/2023 - 596 lbs. on 4/19/2023 - 599 lbs. on 4/19/2023 - 599 lbs. on 5/1/2023 Review of the above weights revealed that the resident had a 58 pound weight gain from 4/8/2023 to 4/12/2023. Additionally, a 45.8 pound weight gain was noted from 3/30/2023 to 5/1/2023 indicating a significant weight gain. Record review revealed Licensed Practical Nurse, Staff A, recorded the weight gain of 611 lbs. on 4/12/2023. During a surveyor interview with Staff A on 7/27/2023 at 2:53 PM, she stated that any weight discrepancy must be reported to the physician. Additionally, she indicated that she would have to re-weigh the resident if there was a significant change in the resident's weight. She was unable to provide evidence that she re-weighed the resident or reported the significant weight gain of 58 lbs. from 3/30/2023 to 4/12/2023 to the physician. Record review failed to reveal evidence that the physician or dietitian were notified, or that an intervention was put in place, related to the significant weight gain on 4/12/2023. Further review failed to reveal evidence that his/her plan of care was updated or that s/he received education regarding the risks of his/her weight gain. During a surveyor interview with the Nurse Practitioner, Staff B, on 7/27/2023 at approximately 3:00 PM, she revealed that she would have expected to be notified of the resident's weight gain. She further indicated that she could not recall if the staff informed her of Resident ID #1's significant weight gain. She stated, whatever is in my progress note is what I know. Record review of a progress note authored by Staff B dated 4/14/2023 failed to reveal evidence that she was made aware of Resident ID #1's 58 pound weight gain. During a surveyor interview with the Director of Nursing Services on 7/27/2023 at 3:15 PM, she stated that she would expect the physician to be notified and was unable to provide evidence that the physician was notified or that an intervention was implemented after the resident's significant weight gain.

Based on record review and staff interview, it has been determined that the facility failed to immediately consult with the resident's physician when there is a significant change in the resident's physical status for 1 of 1 residents who experienced delayed treatment for a deterioration in health, Resident ID #7. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on [DATE] indicates that the resident had an accident which resulted in a transfer to the hospital with a diagnosis of respiratory failure. Record review revealed that the resident was admitted to the facility in April of 2023 with diagnoses including but not limited to, obstructive sleep apnea (a disorder in which a person frequently stops breathing during his or her sleep), and acute and chronic respiratory failure. An admission Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. Record review of a care plan dated [DATE] indicates that s/he has altered respiratory status and difficulty breathing related to sleep apnea. Interventions include but are not limited to, monitor for the following signs and symptoms of respiratory distress and report to the doctor as needed; increased rate of breathing, decreased pulse oximetry (oxygen in the blood), increased heart rate, confusion, and lethargy. The care plan also indicates to monitor, document, and report abnormal breathing patterns such as, increased or decreased rate of breathing, to the physician. Record review revealed a physician's order with a start date of [DATE] for BIPAP (bilevel positive airway pressure which is a type of device that helps with breathing), to be applied every bedtime and removed every morning. Additional record review revealed the following progress notes: [DATE] at 1:56 AM - The note indicates that at 1:50 AM the Nursing Assistant (NA) informed the nurse that the resident was found on his/her knees on the floor of his/her room. The resident was noted with hallucinations and did not know where his/her bed was. The note further indicates that when the nurse entered the room the resident had returned to bed with the assistance from his/her roommate. Additionally, the resident's vital signs were documented as, blood pressure ,d+[DATE] (normal blood pressure is ,d+[DATE]), heart rate 105 (normal range 60 - 100), blood oxygen level of 90% (normal range 95 - 100%). [DATE] at 10:46 AM - The note indicates that the resident was noted to have a blood oxygen level of ,d+[DATE]%. S/he was provided with oxygen at 3 liters per minute via a nasal cannula (oxygen tubing that delivers oxygen through the nose). Additionally, s/he was transferred to the emergency department via rescue. During a surveyor interview on [DATE] at approximately 3:30 PM, with Licensed Practical Nurse (LPN), Staff A, she revealed that she was the nurse on duty during the 11:00 PM - 7:00 AM shift on [DATE]. Additionally, she indicated that a Nursing Assistant informed her of the resident being found on his/her knees at 1:50 AM. She further indicated that when she entered the room the resident was already back in bed but was lying with his/her head at the lower end of the bed and his/her feet at the head of the bed. Staff A revealed that the resident did not have the BIPAP mask on at that time and indicated that the resident was hallucinating. She stated that Resident ID #7's vital signs were good, and indicated that hallucinations were not his/her baseline. Furthermore, Staff A acknowledged that the resident was having a change in condition. Additionally, she acknowledged that she did not speak with the physician but left a voice message for the physician to report the fall and not the change in the resident's condition. When the surveyor asked about the documented vital signs, Staff A, indicated that she checked on the resident however she was unable to provide evidence of a reassessment of his/her vital signs or respiratory status as indicated in the care plan. During a surveyor interview on [DATE] at 9:00 AM with LPN, Staff B, she revealed that she was the nurse on duty on [DATE] during the 7:00 AM - 3:00 PM shift. She indicated that on the morning of [DATE] she was told that the resident fell during the night shift and was hallucinating. She indicated that the resident was confused during breakfast with a low blood oxygen level. She indicated that the resident was transferred to the hospital. Further record review failed to reveal evidence that the resident was monitored for respiratory distress or that the above-mentioned change in the resident's condition; hallucinations and abnormal vital signs, were reported to the physician or nurse practitioner until [DATE] at 10:46 AM. Record review of the hospital document dated [DATE] at 11:15 AM indicates that the resident presented to the hospital for respiratory failure after an unwitnessed fall while receiving blood thinning medication at the nursing facility. S/he was unable to receive a diagnostic scan of the head due to body size. Additionally, the hospital documents revealed that the resident required intubation (a tube inserted through a person's mouth or nose into the airway to provide oxygen) and ultimately expired on [DATE]. During a surveyor interview on [DATE] at 10:15 AM with the Director of Nursing Services (DNS), she was unable to provide evidence that the facility immediately consulted the physician when Resident ID #7 experienced a change in condition on [DATE] at 1:50 AM. Additionally, she was unable to provide evidence that the resident's medical condition was reassessed between 1:55 AM and 10:46 AM. The DNS further indicated that she would have expected the nurse to reassess the resident due to the change in condition, notify the physician, and document in the resident's medical record.

Based on record review and staff interview it has been determined that the facility failed to ensure its nursing staff had the appropriate competencies and skills 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 and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 6 of 6 licensed nursing staff reviewed for competencies relative to the use of non-rebreather masks, Staff A, B, C, E, F and G. Findings are as follows: According to the ScienceDirect Journal article, titled Emergency Oxygen Administration, dated 2008, states in part, .Non-Rebreather Mask 1. The non-rebreather mask is the first choice when considering constant flow supplemental O2 [oxygen] in an acute medical emergency. It consists of a mask, reservoir bag, and two or three one-way valves, one separating the reservoir from the mask and the other one or two on the sides of the mask. Oxygen flows into the reservoir bag so that when the victim inhales, he or she inhales O2 from the reservoir. The one-way valves on the sides of the mask keep air from coming into the mask and diluting the O2. When the victim exhales, expired air goes out of the mask through the one or two valves on the face and is prevented from entering the reservoir .3. To use the mask, it is attached to the O2 supply at a flow rate of 10 to 15 L/minute. The reservoir bag must be inflated or primed before placing it on the person .Care must be taken to not allow the O2 supply to be depleted while the mask is on the person. Because of the one-way valves, if there is no O2 supply, suffocation may result . According to an article published by Osmosis from Elsevier titled, Non-Rebreather Mask, What Is It, When Is It Used, and More, states in part, .A non-rebreather mask requires a sufficient oxygen flow rate to ensure that the oxygen reservoir bag does not collapse when the individual inspires .Therefore, a flow rate of ,d+[DATE] liters per minute is generally recommended .The mask is connected to an oxygen tank via tubes .The minimal flow rate of non-rebreather masks is typically 12 liters per minute to prevent collapse of the bag upon inhalation . The article, Respiratory Acidosis, published by the National Library of Medicine on [DATE] states in part, .Respiratory acidosis typically occurs due to failure of ventilation and accumulation of carbon dioxide. The primary disturbance is an elevated arterial partial pressure of carbon dioxide (pCO2) and a decreased ratio of arterial bicarbonate to arterial pCO2, which results in a decrease in the pH of the blood . Review of the facility assessment revealed that the facility provides care to resident's that require Special Equipment/Needs of oxygen tanks and concentrators. The staff responsible for this are Nursing Management and the Environmental Director. Further review of the facility assessment failed to provide details on how staff are to provide oxygen therapy to its residents, such as nasal cannula or masks. 1. Record review for Resident ID #1 revealed s/he was initially admitted and readmitted to the facility in June of 2023. The resident had medical diagnoses including, but not limited to, atrial fibrillation (irregular and often rapid heart rate), shortness of breath, chronic obstructive pulmonary disease, (COPD), acute on chronic congestive heart failure (CHF-heart pumps inadequately), systolic (your heart isn't contracting well during heartbeats) and diastolic (your heart can't relax normally between beats) heart failure, obstructive sleep apnea, and sick sinus syndrome (a group of heart rhythm problems due to problems with the sinus node). Review of a progress note dated [DATE] at 9:22 AM Authored by Licensed Practical Nurse (LPN), Staff A, states in part, Resident noted to be cyanotic upon arrival to facility this morning. SPO2 [peripheral oxygen saturation] noted to be 90% [normal range is ,d+[DATE]%] @ [at] 2L [LPM; Liters per minute] via NC [nasal cannula]. Resident appeared to be struggling to breathe. O2 removed and resident was placed on a non-rebreather @5L. Spo2 up to 96% but slowly started to drop down to 88%. Resident sent out 911. [nurse practitioner] NP notified, family notified. This writer called [acute care hospital] and report was given to ER [emergency room ] nurse . Record review of the emergency medical services (EMS) Patient Care Report dated [DATE] states in part, .911 call for difficulty breathing and arrived to find [resident] .alert to pain. Patient was short of breath. Staff reported spo2 of 88. Patient was on a non-rebreather at 4LPM .with a deflated bag. Patient switched to non rebreather at 15lpm on portable tank. SpO2 increased to 100 . During a surveyor interview on [DATE] at 11:02 AM, LPN, Staff E, revealed that on the morning of [DATE] he arrived at the facility minutes before 7:00 AM for the start of his shift. He stated that during report about Resident ID #1's from the overnight staff, LPN Staff B, who indicated that the resident was mottled in appearance (discoloration of the skin due to a decrease in blood flow). Staff E indicated that he went to Resident ID #1's room immediately and assessed that s/he was not mottled but cyanotic, with an SPO2 of 91% on 2 liters of oxygen via nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help. This device consists of a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows). He further revealed that he placed a mask on the resident and left the oxygen liter flow at 2 LPM. Additionally, he revealed that he was not assigned to care for Resident ID # 1 that day and that Staff A took over his/her care when she arrived at the facility at approximately 7:20 AM. During a surveyor interview on [DATE] at 2:10 PM with Staff A, she revealed that when she arrived at the facility on [DATE] to start her shift it was approximately 7:20 AM. Staff A indicated that when she went in to assess Resident ID #1 a non-rebreather mask was on him/her and s/he was noted to be, gasping for breath and struggling to breath. Additionally, she revealed that the resident's SPO2 had dropped to 88%. Additional review of the EMS Patient Care Report dated [DATE] revealed that EMS was contacted by the facility at 7:48 AM to transport the resident to the hospital and that they arrived at the facility at 7:54 AM to observe the resident in a nonrebreather mask set at only 4 liters, with the reservoir bag deflated. This indicated that for approximately 50 minutes Resident ID #1 had the non-rebreather mask on him/her with a deflated bag. Record review of Resident ID #1's hospital records dated [DATE] indicated that his/her venous blood gas levels resulted as panic with a pCO2 result of 77.9 and his/her blood pH was 7.130 (normal range is 7XXX,d+[DATE].4500), indicating the resident was in respiratory acidosis. Further review of this document revealed that Resident ID #1 expired on [DATE] at 12:22 PM. 2. Record review for Resident ID #6 revealed s/he was originally admitted to the facility in September of 2020 with diagnoses including but not limited to cerebral infarction (stroke), aphasia following cerebral infarction (loss of ability to understand or express speech, caused by brain damage), dysphagia (difficulty swallowing ), hemiplegia (paralysis of one side of the body) affecting left non-dominant side. Review of a progress note dated [DATE] at 11:38 AM Authored by LPN, Staff G, states in part, .pt [patient] send by 911 due to increase congestion, with pt continue to d-sat [desaturate; when the amount of oxygen bound to the hemoglobin in your blood drops below the normal levels], non re breather [mask] on with very little result, NP called to send pt Out .report given to nurse in ER. Further record review revealed that the resident was transferred to the local acute care hospital on [DATE]. Review of Resident ID #6's hospital record for the above-mentioned date states in part, .in from [his/her] facility due to concern for increased shortness of breath this morning. No reported recent fevers documented but patient was diaphoretic per staff. Patient was hypoxic in the 70s on a non rebreather but EMS noted that when they arrived, staff not connected the tubing to the nonrebreather appropriately. [S/he] immediately had improvement to the 90s when they placed [him/her] on CPAP during transport. During a surveyor interview with Staff G on [DATE] at approximately 11:00 AM she indicated that she placed Resident ID #6 on 10 liters of oxygen via a non- rebreather mask on [DATE] and the bag was fully inflated on the mask. However, when the surveyor revealed that the EMS had reported that the bag of the mask was deflated on arrival to the facility on [DATE], she recanted her statement. She then indicated that she placed the non-rebreather mask on Resident ID #6 with the bag deflated stating she was fighting with the mask to try to get the bag inflated. Additionally, she revealed that the resident's Spo2 level did not increase when the mask was placed on him/her and that she did not try switching out the mask for another one. She further revealed that she left the deflated non-rebreather mask on Resident ID #2 until s/he was transported to the hospital by EMS. Additional review of the hospital record dated [DATE] revealed Resident ID #6's venous blood gas results were abnormal with a pCO2 level of 60.5 and his/her blood pH was 7.023, indicating s/he was in respiratory acidosis. Record review of the EMS Patient Care Report reveals that EMS was called to the facility on [DATE] at 11:20 AM and they arrived at the facility at 11:28 AM. Upon arrival, EMS noted Resident ID #6's SPO2 level was 72% and s/he was found with a non-rebreather mask on with an empty reservoir bag. Additionally, the document further reveals that when EMS placed the resident on CPAP and his/her oxygen level increased to 80% and then to 94% after they administered a nebulizer treatment and placed the CPAP on 6 liters of oxygen. Additional review of Resident ID #6's hospital record revealed s/he expired on [DATE] at 7:26 PM. As a result of the concerns that were identified during this survey a review of licensed nursing staff, A, B, C, E, F and G's competencies were conducted. Record review failed to reveal evidence of completed competencies or education were provided to the above mentioned staff, relative to the use of non-rebreather masks. During a surveyor interview with the Staff Educator on [DATE] at 2:12 PM she was unable to provide evidence that Staff A, B, C, E, F and G had received competency training on the use of non-rebreather masks. During a surveyor interview on [DATE] at 1:24 PM with the Medical Director, he revealed that he would expect that staff would have been provided the necessary training to use the equipment supplied to them by the facility to care for the residents. During a surveyor interview with the Administrator on [DATE] at 2:51 PM she was unable to provide evidence that Staff A, B, C, E, F and G had the specific skill sets necessary to care for Resident ID #1 and 6's needs pertaining to the use the non-rebreather mask. During a surveyor interview on [DATE] at approximately 2:15 PM with the Administrator and Director of Nursing Services, they acknowledged that the nursing staff had not been provided with competencies relative to the use of non-rebreather masks until after it was brought to their attention by the surveyors. As a result of the system failure to ensure licensed nursing staff had the appropriate competencies and skill sets to assure resident safety, Resident ID #s 1 and 6 were placed at serious harm, impairment, or death by the facility. Refer to F 695

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 3 residents reviewed who received oxygen therapy via a nonrebreather mask, Resident ID #s 1 and 6. Findings are as follows: According to the ScienceDirect Journal article, titled Emergency Oxygen Administration, dated 2008, states in part, .Non-Rebreather Mask 1. The non-rebreather mask is the first choice when considering constant flow supplemental O2 in an acute medical emergency. It consists of a mask, reservoir bag, and two or three one-way valves, one separating the reservoir from the mask and the other one or two on the sides of the mask. Oxygen flows into the reservoir bag so that when the victim inhales, he or she inhales O2 from the reservoir. The one-way valves on the sides of the mask keep air from coming into the mask and diluting the O2. When the victim exhales, expired air goes out of the mask through the one or two valves on the face and is prevented from entering the reservoir .3. To use the mask, it is attached to the O2 supply at a flow rate of 10 to 15 L/minute. The reservoir bag must be inflated or primed before placing it on the person .Care must be taken to not allow the O2 supply to be depleted while the mask is on the person. Because of the one-way valves, if there is no O2 supply, suffocation may result . According to an article published by Osmosis from Elsevier titled, Non-Rebreather Mask, What Is It, When Is It Used, and More, states in part, .A non-rebreather mask requires a sufficient oxygen flow rate to ensure that the oxygen reservoir bag does not collapse when the individual inspires .Therefore, a flow rate of ,d+[DATE] liters per minute is generally recommended .The mask is connected to an oxygen tank via tubes .The minimal flow rate of non-rebreather masks is typically 12 liters per minute to prevent collapse of the bag upon inhalation . Record review for Resident ID #1 revealed s/he was admitted to the facility in June of 2023. The resident has medical diagnoses including, but not limited to, atrial fibrillation (irregular and often rapid heart rate), shortness of breath, chronic obstructive pulmonary disease, (COPD), acute on chronic congestive heart failure (CHF-heart pumps inadequately), systolic (your heart isn't contracting well during heartbeats) and diastolic (your heart can't relax normally between beats) heart failure, obstructive sleep apnea, and sick sinus syndrome (a group of heart rhythm problems due to problems with the sinus node). Record review of the nursing progress notes revealed the following: -[DATE] at 5:30 AM authored by Licensed Practical Nurse (LPN), Staff B states in part, Resident lethargic. Unable to get resident to wake up. Medications held. -[DATE] at 9:22 AM Authored by LPN, Staff A, states in part, Resident noted to be cyanotic upon arrival to facility this morning. SPO2 [peripheral oxygen saturation] noted to be 90% [normal range is ,d+[DATE]%] @ [at] 2L [LPM; Liters per minute] via NC [nasal cannula]. Resident appeared to be struggling to breathe. O2 removed and resident was placed on a non-rebreather @5L. Spo2 up to 96% but slowly started to drop down to 88%. Resident sent out 911. [nurse practitioner] NP notified, family notified. This writer called [acute care hospital] and report was given to ER [emergency room ] nurse . -[DATE] at 12:57 PM authored by Staff A, states in part, .told by ER nurse that resident had passed away r/t [related to] end stage COPD. During a surveyor interview on [DATE] at 8:35 AM with Staff B, she revealed that she cared for the resident on [DATE] ,d+[DATE] PM shift and [DATE] the ,d+[DATE] overnight shift. She revealed that she had placed the resident on 2 liters of oxygen via nasal cannula that night and monitored his/her SPO2 levels, which were maintained between ,d+[DATE]%. She further revealed that during the overnight shift it was reported to her by Nursing Assistant, Staff D, that Resident ID #1 was noted without his/her oxygen tubing, further revealing the tubing was rolled up at the foot of Resident ID #1's bed. She further revealed that she suspected that Resident ID #1's roommate, Resident ID #2, had removed his/her tubing as Resident ID #1 was unable to remove his/her own tubing. Staff B further revealed that Resident ID #2 was observed by staff standing over Resident ID #1 during the night and that s/he was subsequently escorted out of the room in the early morning at approximately 5:15 AM. Additionally, Staff B revealed at approximately 5:30 AM she obtained Resident ID #1's fingerstick blood sugar, however she was unable to administer the resident's medications. Lastly, she revealed that Staff E came in for the morning shift at approximately 7:00 AM and she reported to him that Resident ID #1 was snoring and that she was unable to administer his/her medications because she could not wake him/her. She also revealed that she told Staff E that the resident's skin was looking darker than usual. Staff E then attended to the resident. During a surveyor interview on [DATE] at 11:02 AM with LPN, Staff E, he revealed that on the morning of [DATE] he arrived at the facility minutes before 7:00 AM for the morning shift and he was alerted to Resident ID #1's room by the overnight staff due to concerns that the resident was mottled in appearance (discoloration of the skin due to a decrease in blood flow). Staff E and another nurse, Registered Nurse, Staff F, entered the resident's room to find the resident in respiratory distress, cyanotic, with an SPO2 of 91% on 2 liters of oxygen via nasal cannula. Staff E revealed the resident's respiratory distress worsened, further describing that the resident displayed agonal breathing (insufficient breathing that may sound like gasping, labored breathing, snoring, or snorting). Staff E then obtained vital signs in which he reported to the oncoming nurse assigned to care for Resident ID #1, and that she needed to call 911. Lastly, Staff E was asked by this surveyor if he had administered a nebulizer treatment (liquid medication inhaled to assist with opening the airway) to the resident when s/he was found in respiratory distress, he responded that he did not, and was not aware if the resident had an order for one. Record review of Resident ID #1's Medication Administration Record (MAR) revealed s/he had a physician's order for an Albuterol nebulizer treatment to be administered every six hours as need for shortness of breath. Further review of the MAR failed to reveal evidence that this nebulizer treatment was administer to Resident ID #1 when s/he was found to be cyanotic and in respiratory distress by Staff E on [DATE]. During a subsequent surveyor interview and simultaneous observation on [DATE] at approximately 2:00 PM with Staff E, he was asked about his statement provided for the facility investigation in which he mentioned that a non-rebreather mask was applied to the resident on the morning that s/he was sent to the hospital. Staff E was asked if he could provide this surveyor with the mask that he applied to Resident ID #1 on [DATE]. Staff E revealed there was only one mask, and he retrieved a non-rebreather mask from a container located in the medication room behind the nurse's station. The container was observed with only non-rebreather masks. Staff E further revealed that the resident was on oxygen at 2 liters via NC, Staff E replaced the NC tubing with the nonrebreather mask and tubing and attached that to the concentrator. Additionally, he indicated that when he applied the non-rebreather mask to Resident ID #1, he did not adjust/increase the oxygen flow rate from 2 liters. Of note, the oxygen concentrator does not deliver more than 5 liters of oxygen per minute. During a surveyor interview on [DATE] at 12:20 PM with Staff F, she revealed on [DATE] she was made aware by staff that Resident ID #1 did not look well and was mottling. Staff F revealed that she and Staff E went into Resident ID #1's room. Upon entering the room Resident ID #1 was noted on oxygen via NC, in moderate respiratory distress, with his/her fingers and toes blue in appearance. Additionally, she revealed the resident would only open his/her eyes to a hard rub to the chest and then close them. During a surveyor interview on [DATE] at 2:10 PM with Staff A, she revealed when she arrived to the facility it was approximately 7:20 AM. Staff A revealed upon arriving to Resident ID #1's room, s/he was already cared for by Staff E and in a non-rebreather mask with his/her SPO2 at ,d+[DATE]%, gasping for breath and struggling to breath. Staff A revealed that Staff E obtained another set of vital signs and the resident's SPO2 was now at 88%. Lastly, Staff A revealed she notified the provider at 7:35 AM that the resident needed to go out and she was not sure of the time when 911 arrived. Record review of the document titled RI EMS [Emergency Medical Services] Patient Care Report dated [DATE] with a time of 7:50 AM for Resident ID #1 revealed EMS was dispatched to the nursing home for Resident ID #1 for difficulty breathing. Upon arrival the resident was short of breath. Staff reported SPO2 of 88% and the patient was noted to be on a nonrebreather mask at 4 liters per minute on a compressor with a deflated bag. Resident ID #1 was then switched to a nonrebreather mask at 15 liters via a portable tank and his/her SPO2 increased to 100%. The patient was then moved to a stretcher and wheeled to the rescue for transport to the hospital. The patient was administered a nebulizer treatment via aerosol mask at 6 liters. The patient was then taken into the emergency room , and s/he became unresponsive. Record review of Resident ID #1's hospital records dated [DATE] indicated that his/her venous blood gas levels resulted as panic with a pCO2 result of 77.9 and his/her blood pH was 7.130 (normal range is 7XXX,d+[DATE].4500), indicating the resident was in respiratory acidosis, (a condition that occurs when your lungs can't remove all of the carbon dioxide produced by your body. This causes the blood and other body fluids to become too acidic. Acute respiratory acidosis occurs when carbon dioxide builds up very quickly). Further review of this document revealed that Resident ID #1 expired on [DATE] at 12:22 PM. Further review of all the documentation surrounding this incident revealed that Resident ID #1 was noted to be in respiratory distress at the facility by Staff E and Staff F moments before 7:00 AM. Staff A arrived at approximately 7:20 AM, she also noted the resident was in respiratory distress, she was given details of what occurred and was told 911 needed to be called. The on-call provider was contacted at 7:35 AM (which was approximately 15 minutes later) to notify them that the resident needed to go to the hospital for further evaluation. According to the EMS Report, EMS was contacted by the facility at 7:48 AM to transport the resident to the hospital for difficulty breathing. It is also noted that EMS arrived at the facility at 7:54 AM to observe the resident in a nonrebreather mask at only 4 liters, with the reservoir bag deflated and the mask supplying the resident with insufficient oxygen. In conclusion, from the time the resident was noted to be in respiratory distress to the time s/he received adequate oxygenation and a nebulizer treatment to increase his/her oxygen status, was approximately 50 minutes. 2. Record review for Resident ID #6 revealed s/he was readmitted to the facility in May of 2023. The resident has medical diagnoses including, but not limited to, pneumonia, stroke, atrial fibrillation, and hypertension. Record review of the nursing progress notes revealed the following: -[DATE] at 8:50 AM, authored by LPN, Staff G, states in part, .vs [vital signs] ,d+[DATE], 97.4 91 spo2 in 2 L [liters], neb treatment given with pain med with very little relief, call placed to doctor on call again, awaiting call back . -[DATE] at 10:32 AM, authored by Staff G, states in part, .NP called back for [physician], order obtain[ed] for Augmentin [antibiotic] ,d+[DATE] bid x 7 days . -[DATE] at 11:38 AM, authored by Staff G, states in part, .send by 911 due to increase congestion, with pt [patient] continue to d-sat [desaturatetion-amount of oxygen drops below the normal level], non re breather on with very little result . -[DATE] at 3:47 PM, states in part, .Resident was admitted at [hospital name redacted] with DX [diagnosis] Acute Respiratory Failure with Hypoxia. Record review of the document titled RI EMS [Emergency Medical Services] Patient Care Report dated [DATE] with a time of 11:22 AM for Resident ID #6 revealed EMS was dispatched to the nursing home for the resident due to him/her having difficulty breathing. Upon arrival the resident was found lying in bed with audible gurgling. The document further revealed that the patient had been recently diagnosed with pneumonia and s/he had a nonrebreather mask placed prior to EMS arrival, with the reservoir bag empty. The nonrebreather was removed by EMS and the resident was placed in a CPAP [a device that provides pressured air to keep breathing airways open] and his/her oxygen level rose from 72% to 80%. Additionally, the document revealed that the resident was then given a nebulizer treatment with the CPAP at 6 liters per minute and the patient's oxygen level rose to 94% with treatment. Lastly, the report revealed a documented SPO2 of 98% after treatment. During a surveyor interview with Staff G on [DATE] at approximately 11:00 AM she indicated that she placed Resident ID #6 on 10 liters of oxygen via a non- rebreather mask on [DATE] and the bag was fully inflated on the mask. However, when the surveyor revealed that the EMS had reported that the bag of the mask was deflated on arrival to the facility on [DATE], she recanted her statement. She then indicated that she placed the non-rebreather mask on Resident ID #6 with the bag deflated stating she was fighting with the mask to try to get the bag inflated. Additionally, she revealed that the resident's Spo2 level did not increase when the mask was placed on him/her and that she did not try switching out the mask for another one. She further revealed that she left the deflated non-rebreather mask on Resident ID #2 until s/he was transported to the hospital by EMS. During a surveyor interview on [DATE] at 11:18 AM with Nursing Assistant, Staff H, she revealed she was providing care to Resident ID #6 and noticed his/her breathing had changed and went to get the nurse. She further revealed that Staff G came in to assess the resident, brought the oxygen cylinder in the room and applied the non-rebreather mask and hooked it up the oxygen tank. She further revealed that the bag wouldn't inflate. Staff H then left the room to get the supervisor. Record review of the Hospital Emergency Department Code/Rapid Response report revealed the resident's diagnoses that were active upon admission were as follows, acute respiratory failure with hypoxia, atrial fibrillation with rapid ventricular response (rapid atrial contractions of the heart that cause the ventricles to beat too quickly resulting in a lack of oxygenated blood) pleural effusion (buildup of fluid between the tissues that line the lungs and the chest), pneumothorax (collapsed lung) and sepsis (a life-threatening complication from an infection). The report indicated that the resident was noted to be ill-appearing and toxic-appearing with tachypnea (breathing that is abnormally rapid and shallow with decreased breath sounds). Further review of the hospital report revealed the resident's lab results indicated the resident was in respiratory acidosis (a state in which there is usually ventilation failure and an accumulation of carbon dioxide). Additionally, review of the report indicates that when EMS arrived to the nursing home the resident was diaphoretic and hypoxic in the 70's on a nonrebreather. EMS also noted when then they arrived to the nursing home, nursing home staff had not connected the tubing to the nonrebreather appropriately. His/her SPO2 levels immediately improved into the 90's when EMS places him/her on CPAP during transport to the hospital. Additional review of the hospital record dated [DATE] revealed Resident ID #6's venous blood gas results were abnormal with a pCO2 level of 60.5 and his/her blood pH was 7.023, indicating s/he was in respiratory acidosis and that s/he expired on [DATE]. During a surveyor interview on [DATE] at 1:24 PM with the Medical Director, he revealed that he would expect that staff would know how to use the nonrebreather masks. During a surveyor interview on [DATE] at approximately 2:15 PM with the Administrator and Director of Nursing Services, they were unable to provide evidence that respiratory services were provided consistent with professional standards of practice. Resident ID #'s 1 and 6 were placed at serious harm, impairment or death by the facility. The facility failed to provide respiratory care consistent with professional standards of practice potentially contributing to their deaths. 40705

Based on record review and staff interview it has been determined that the facility failed to protect and keep residents free from physical abuse relative to an incident that occurred between Resident ID #1 and 2. Findings are as follows: On [DATE] the Rhode Island Department of Health received a community reported complaint that indicates Resident ID #2 removed his/her roommate's [Resident ID #1's] supplemental oxygen supply. Resident ID #1 subsequently decompensated and died at the hospital. Record review for Resident ID #1 revealed s/he was initially admitted and readmitted to the facility in June of 2023. The resident had medical diagnoses including, but not limited to, atrial fibrillation (irregular and often rapid heart rate), shortness of breath, chronic obstructive pulmonary disease, (COPD), acute on chronic congestive heart failure (CHF-heart pumps inadequately), systolic (your heart isn't contracting well during heartbeats) and diastolic (your heart can't relax normally between beats) heart failure, obstructive sleep apnea, and sick sinus syndrome (a group of heart rhythm problems due to problems with the sinus node). 1. Record review reveals Resident ID #1 (alleged victim) was originally admitted to the facility on [DATE] from an acute care hospital with diagnoses of multiple contusions and falls. During the hospitalization the resident wanted to be discharged home against medical advice but subsequently agreed to a skilled nursing facility (SNF) for rehabilitation. S/he was evaluated by therapy with recommendations for short term rehab and further management of care. Record review of Resident ID #1's care plan dated [DATE] indicates that the resident utilizes oxygen therapy related to congestive heart failure (CHF), respiratory illness and COPD, ,d+[DATE] liters as needed. The goal of the care plan is that the resident will have no signs or symptoms of poor oxygen [O2] absorption through the next review date. Record review reveals the following progress notes regarding the health status of Resident ID #1: - [DATE] - Nurse Practitioner (NP), initial encounter note authored by NP, Staff I indicates the resident had clear lung sounds and was in no acute distress. - [DATE] 4:09 AM- a note authored by Registered Nurse (RN), Staff J, indicates that Resident ID #1 is alert and requires assistance with care. S/he was in bed most of the shift. The resident did not complain of any pain or discomfort and no respiratory or cardiac distress were noted. - [DATE] at 12:09 PM- a note authored by the Activities Director, indicates that Resident ID #1 stated s/he was only here for a short stay and wants to return home. - [DATE] at 9:01 AM- a note authored by RN, Staff F, indicates that Resident ID #1 was complaining of shortness of breath. S/he had an audible wheeze and blue tinged lips. His/her lung sounds were diminished bilaterally, and the resident was unable to cough effectively. The resident's oxygen level was 92 to 94% (normal oxygen saturation is 95%-100%) on 2 liters of oxygen. (Although, record review reveals that the resident did not have an active order for oxygen at this time). - [DATE] at 12:43 PM- a note authored by Staff F indicates that Resident ID #1 continued to become more lethargic and required more oxygen. The resident was on 3 liters of oxygen via nasal cannula (NC) [oxygen tubing that delivers oxygen through the nose] with an oxygen saturation level at 92% (Although, record review reveals that the resident did not have an active order for oxygen at this time). The resident was unable to take his/her medications secondary to lethargy. The resident was sent out to the hospital via 911 and subsequently admitted with a diagnosis of CHF exacerbation. - [DATE]- a note authored by Staff J indicates that Resident ID #1 returned back to the SNF from the hospital after being admitted for CHF exacerbation. On assessment the resident was noted to have an oxygen saturation level of 97% on room air. The resident was comfortable in bed at this time. - [DATE] at 3:17 AM- a note authored by Licensed Practical Nurse (LPN), Staff B, indicates that Resident ID #1 was sleeping comfortably in his/her bed. The resident's respirations were 18 (normal respirations ,d+[DATE]) with some episodes of chest breathing. Resident ID #1's oxygen saturation level was 91 to 92% on room air. - [DATE] at 7:15 AM - a note authored by Staff B indicates the resident had no cardiac or respiratory distress noted. - [DATE]- a note authored by LPN, Staff A, indicates the resident was more alert this shift. Family in to visit and pleased that Resident ID #1 was able to hold short conversations with them. 2. Record review for Resident ID #2 (alleged perpetrator) revealed s/he was admitted to the facility in October of 2022. The resident has medical diagnoses including, but not limited to, dementia, stroke, and anxiety disorder. Record review of a Quarterly MDS Assessment, Section C, dated [DATE] revealed a Brief Interview for Mental Status Assessment which the resident scored a 7 out of 15 indicating s/he had severe cognitive impairment. Record review of Resident ID #2's care plan developed on [DATE] states in part, [Resident] has a behavior problem as evidenced by physically remove [ing] other residents from their seat in the dining room, can be very territorial. Has difficulty with roommates, complains about noise, TV and can be paranoid at times . The care plan interventions include, but are not limited to, .Intervene as necessary to protect the rights and safety of others .Divert attention. Remove from situation and take to alternate location as needed . Further record review of the care plan for Resident ID #2 failed to reveal evidence of a level of supervision that was required if/when s/he had behaviors with other residents and/or roommates. Record review revealed that on [DATE] Resident ID #1 was found without his/her oxygen on numerous occasions. Record review revealed the following events/incidents occurred on [DATE] thorugh [DATE]: - [DATE] at approximately 5:30 PM Resident ID #2 had lined up juice and milk cups at the foot of Resident ID #1's bed. Nursing Assistant (NA), Staff D, asked Resident ID #2 to not put his/her cups on Resident ID #1's bed. Resident ID #2 responded, go f*** yourself. - [DATE] at approximately midnight Resident ID #1's oxygen concentrator was alarming. Staff D entered the room and turned the oxygen concentrator off and then back on and the concentrator stopped alarming. - [DATE] at 12:15 AM Resident ID #1's oxygen concentrator was again alarming. Staff D replaced the concentrator. - [DATE] at approximately 2:00 AM Staff D went to answer a call light and on the way back, she checked on Resident ID #1. [His/her] oxygen was off, so I put it back on. - [DATE] at 2:30 AM- Resident ID #2 rang his/her call bell and said, this f****** [ guy/gal] is making a lot of noise. Upon observation Resident ID #1's O2 was off again. - [DATE] at 3:30 AM- Resident ID #1's call bell was ringing. Staff D asked Resident ID #2 if s/he had pressed the call light. Resident ID #2 indicated that Resident ID #1 needed help and s/he pulled the call light him/herself. At this time Staff D noted that the nasal cannula was again off. Staff D questioned Resident ID #2 and asked if s/he has been taking off Resident ID #1's oxygen. Resident ID #2 responded it's not me .It's f******* [him/her] .I have put up with [his/her] f****** noise all night I want [him/her] f****** out of here now .I'll f****** push [him/her] into the hallway myself . - [DATE] at 4:53 AM -a note authored by Staff B states, Resident upset about roommate making noise all night (roommate is a mouth breather and snores). Resident stated that [s/he] can not stand the noise [s/he] is going to push [him/her] out in the hall. Resident has been taking roommates oxygen off and stating to get [him/her] out of here. Resident has been found standing over roommate multiple times, just staring at roommate. - [DATE] at 5:15 AM- Staff B observed Resident ID #1's nasal cannula tubing off his/her nose. It was nicely rolled up at the foot Resident ID #1's bed. - [DATE] at approximately 6:15 AM- Resident ID #2 was standing over his/her roommate, Resident ID #1's nasal cannula was off again. - [DATE] at 6:34 AM- a note authored by Staff B, states in part, Resident told this writer that [s/he] was going down to get something to snack from the vending machine. Staff member found resident in dining room taking sugar. When staff member told [him/her] that [s/he] is not supposed to be behind the double doors at this time, resident swung [his/her] cane at him. Resident refused to have [his/her] blood sugar checked this morning . - [DATE] at 7:15 AM- a note authored by Staff B, states in part, .behaviors during the night was reported to [name redacted] on call .She also stated that we should keep resident and roommate separate until then. - [DATE] at 9:22 AM - a note authored by LPN, Staff A, states in part, Resident noted to be cyanotic upon arrival to facility this morning. SPO2 [peripheral oxygen saturation] noted to be 90% @ [at] 2L [LPM; Liters per minute] via NC. Resident appeared to be struggling to breathe. O2 removed and resident was placed on a non-rebreather @5L. Spo2 up to 96% but slowly started to drop down to 88%. Resident sent out 911. NP notified, family notified. This writer called [acute care hospital] and report was given to ER [emergency room ] nurse . - [DATE] at 10:54 AM - a note authored by Staff B, (this note was written by Staff B after Resident ID #1 had already been transported to the hospital) states in part, Resident does not realize that removing [his/her] roommates oxygen is harmful to the roommate .Resident believed the oxygen was what was making all the loud noises .After this talk room was closely monitored, by door being left open. Staff member within could see roommate clearly from the hallway due to roommat's bed being close to door. Resident did leave unit to go to vending machine and upon return went into day room. - [DATE] at 12:57 PM - a note authored by Staff A, states in part, .told by ER nurse that resident had passed away r/t [related to] end stage COPD. During a surveyor interview with Staff B on [DATE] at 9:37 AM she indicated that she felt Resident ID #1 was not end of life during her shift. [S/he] was [his/her] normal self all night long]. During a surveyor interview with Registered Nurse, Staff C, who worked the 3 PM to 11 PM shift on [DATE], she indicated that Resident ID #1 took his/her evening medications and was not in respiratory distress. Staff C had no concerns that Resident ID #1 was at end of life. During a surveyor interview with Staff D on [DATE] at 2:20 PM she revealed that she cared for Resident ID #1 on [DATE] on the 3 PM to 11 PM shift and [DATE] on the 11 PM to 7 AM overnight shift. She indicated that at approximately 5:30 PM on [DATE] Resident ID #2 was standing at the foot of Resident ID #1's bed and was lining up juice and milk cups at the foot of the bed. Staff D indicated that when she questioned Resident ID #2 on what s/he was doing s/he replied with go f*** yourself. She indicated that at approximately 12:00 AM Resident ID #1's oxygen concentrator was alarming. She went into the room and turned the concentrator off and then on and the beeping stopped. She further indicated at 12:15 AM the concentrator started alarming again and she replaced the old concentrator with a new concentrator. Staff D indicated that she went to answer a call light at approximately 2:30 AM and on her way back she noticed that the nasal cannula for Resident ID #1 was not in his/her nose. The nasal cannula was located on the side of Resident ID #2. Staff D indicated that at this time Resident ID #2 was standing at the head of Resident ID #1's bed. At 2:30 AM Resident ID #2 rang his/her call light and at that time she noticed that the nasal cannula for Resident ID #1 was laying on the bed. Staff D further indicated that at 3:30 AM Resident ID #1's nasal cannula was again off his/her nose and by his/her stomach. Staff D indicated the last time she saw Resident ID #1's nasal cannula off was at approximately 6:30 AM on [DATE] when Resident ID #2 was again standing over Resident ID #1. The surveyor questioned Staff D on if Resident ID #1 could remove his/her own oxygen and she replied no way [s/he] could do that. During a surveyor interview on [DATE] at 8:35 AM with Staff B she revealed that she cared for Resident ID #1 on [DATE] ,d+[DATE] PM shift and [DATE] on the ,d+[DATE] overnight shift. She revealed that during the overnight shift it was reported to her by Staff D, that Resident ID #1 was noted without his/her oxygen tubing, further revealing the tubing was rolled up at the foot of Resident ID #1's bed. She further revealed that she suspected that Resident ID #2, had removed Resident ID #1's oxygen tubing as s/he was unable to remove his/her own tubing. Staff B further revealed that Resident ID #2 was observed by staff standing over Resident ID #1 during the night and that s/he was subsequently escorted out of the room in the early morning at approximately 5:15 AM. Lastly, she revealed that LPN, Staff E came in for the morning shift at approximately 7:00 AM and she reported to him that Resident ID #1 was snoring and that she was unable to administer his/her medications because she could not wake him/her. She also revealed that she told Staff E that the resident's skin was looking darker than usual. Staff E then attended to the resident. During a surveyor interview on [DATE] at 11:02 AM with LPN, Staff E, he revealed that on the morning of [DATE] he arrived at the facility minutes before 7:00 AM for his shift and he was alerted to Resident ID #1's room by the overnight staff due to concerns that the resident was mottled in appearance (discoloration of the skin due to a decrease in blood flow). Staff E and another nurse Staff F, entered the resident's room to find the resident in respiratory distress, cyanotic, with an SPO2 of 91% on 2 liters of oxygen via nasal cannula. Staff E revealed the resident's respiratory distress worsened, further describing that the resident displayed agonal breathing (insufficient breathing that may sound like gasping, labored breathing, snoring, or snorting). Staff E then obtained vital signs in which he reported to the oncoming nurse, Staff A, who was assigned to care for Resident ID #1, and that she needed to call 911. Record review of Resident ID #1's hospital records dated [DATE] indicated that his/her venous blood gas levels resulted as panic with a pCO2 result of 77.9 and his/her blood pH was 7.130 (normal range is 7XXX,d+[DATE].4500), indicating the resident was in respiratory acidosis, (a condition that occurs when your lungs can't remove all of the carbon dioxide produced by your body. This causes the blood and other body fluids to become too acidic. Acute respiratory acidosis occurs when carbon dioxide builds up very quickly). Further review of this document revealed that Resident ID #1 expired on [DATE] at 12:22 PM. During a surveyor interview on [DATE] at approximately 10:00 AM with the Administrator and Director of Nursing Services they were unable to provide evidence that Resident ID #1 was kept free from abuse as evidenced by Resident ID #2 removing Resident ID #1's supplemental oxygen. Although the facility care planned Resident ID #2 as being very territorial, physically removing others from seats, having difficulty with roommates, complaining about noise, and has paranoia, the care plan failed to reveal evidence of a level of supervision that was required if/when s/he had behaviors with other residents and/or roommate. Additionally, the facility was aware of Resident ID #2's history with roommates, and they placed Resident ID #1, a compromised and vulnerable individual as his/her roommate. Record review failed to reveal evidence that the facility provided appropriate interventions or increased supervision for Resident ID #1 and Resident ID #2 when Resident ID #1 was found without his/her supplemental oxygen or when Resident ID #2 was found standing over his/her roommate and staff was concerned that Resident ID #2 was removing Resident ID # 1's supplemental oxygen on the following dates and times: - [DATE] at 2:00 AM - [DATE] at 2:30 AM - [DATE] at 3:30 AM - [DATE] at 5:15 AM - [DATE] at 6:15 AM Additionally, when Resident ID #2 complained about the noise and indicated s/he was going to physically remove the resident from the room on [DATE] the facility failed to intervene and provide appropriate interventions for Resident ID #1 and 2 which had the potential to cause serious injury, impairment, or death. Refer to F 689

Based on record review and staff interview it has been determined that the facility failed to ensure that each resident receives adequate supervision based on the resident's assessed needs, care plan, risks, and current professional standards of practice relative to an incident that occurred between Resident ID #1 and Resident ID #2. Findings are as follows: On [DATE] the Rhode Island Department of Health received a community reported complaint that indicates Resident ID #2 removed his/her roommate's [Resident ID #1's] supplemental oxygen supply. Resident ID #1 subsequently decompensated and died at the hospital. 1. Record review for Resident ID #1 (alleged victim) revealed s/he was initially admitted and readmitted to the facility in June of 2023. The resident had medical diagnoses including, but not limited to, atrial fibrillation (irregular and often rapid heartrate), shortness of breath, chronic obstructive pulmonary disease, (COPD), acute on chronic congestive heart failure (CHF-heart pumps inadequately), systolic (your heart isn't contracting well during heart beats) and diastolic (your heart can't relax normally between beats) heart failure, obstructive sleep apnea, and sick sinus syndrome (a group of heart rhythm problems due to problems with the sinus node). Record review reveals Resident ID #1 was originally admitted to the facility on [DATE] from an acute care hospital with diagnoses of multiple contusions and falls. During the hospitalization the resident wanted to be discharged home against medical advice but subsequently agreed to a skilled nursing facility (SNF) for rehabilitation. S/he was evaluated by therapy with recommendations for short term rehab and further management of care. Record review of Resident ID #1's care plan dated [DATE] indicates that the resident utilizes oxygen therapy related to congestive heart failure, respiratory illness and COPD, ,d+[DATE] liters as needed. The goal of the care plan is that the resident will have no signs or symptoms of poor oxygen [O2] absorption through the next review date. Record review reveals the following progress notes regarding the health status of Resident ID #1: - [DATE] - Nurse Practitioner (NP), initial encounter note authored by NP, Staff I indicated the resident had clear lung sounds and was in no acute distress. - [DATE] 4:09 AM- a note authored by Registered Nurse (RN), Staff J, indicates that Resident ID #1 is alert and requires assistance with care. S/he was in bed most of most of the shift. The resident did not complain of any pain or discomfort and no respiratory or cardiac distress were noted. - [DATE] at 12:09 PM- a note authored by the Activities Director, indicates that Resident ID #1 stated s/he was only here for a short stay and wants to return home. - [DATE] at 9:01 AM- a note authored by RN, Staff F, indicates that Resident ID #1 was complaining of shortness of breath. S/he had an audible wheeze and blue tinged lips. His/her lung sounds were diminished bilaterally, and the resident was unable to cough effectively. The resident's oxygen level was 92 to 94% (normal oxygen saturation is 95%-100%) on 2 liters of oxygen. (Although, record review reveals that the resident did not have an active order for oxygen at this time). - [DATE] at 12:43 PM- a note authored by Staff F indicates that Resident ID #1 continued to become more lethargic and required more oxygen. The resident was on 3 liters of oxygen via nasal cannula (NC) [oxygen tubing that delivers oxygen through the nose] with an oxygen saturation level at 92% (Although, record review reveals that the resident did not have an active order for oxygen at this time). The resident was unable to take his/her medications secondary to lethargy. The resident was sent out to the hospital via 911 and subsequently admitted with a diagnosis of CHF exacerbation. - [DATE]- a note authored by RN; Staff J indicates that Resident ID #1 returned back to the SNF from the hospital after being admitted for CHF exacerbation. On assessment the resident was noted to have an oxygen saturation level of 97% on room air. The resident was comfortable in bed at this time. - [DATE] at 3:17 AM- a note authored by Licensed Practical Nurse (LPN), Staff B, indicates that Resident ID #1 was sleeping comfortably in his/her bed. The resident's respirations were 18 (normal respirations ,d+[DATE]) with some episodes of chest breathing. Resident ID #1's oxygen saturation level was 91 to 92% on room air. - [DATE] at 7:15 AM - a note authored by Staff B indicates the resident had no cardiac or respiratory distress noted. - [DATE]- a note authored by LPN, Staff A, indicates the resident was more alert this shift. Family in to visit and pleased that Resident ID #1 was able to hold short conversations with them. 2. Record review for Resident ID #2 revealed s/he was admitted to the facility in October of 2022. The resident has medical diagnoses including, but not limited to, dementia, stroke, and anxiety disorder. Record review of a Quarterly MDS Assessment, Section C, dated [DATE] revealed a Brief Interview for Mental Status Assessment which the resident scored a 7 out of 15 indicating s/he had severe cognitive impairment. Record review of Resident ID #2's care plan developed on [DATE] states in part, [Resident] has a behavior problem as evidenced by physically remove [ing] other residents from their seat in the dining room, can be very territorial. Has difficulty with roommates, complains about noise, TV and can be paranoid at times . The care plan interventions included, but are not limited to, .Intervene as necessary to protect the rights and safety of others .Divert attention. Remove from situation and take to alternate location as needed . Further record review of the care plan for Resident ID #2 failed to reveal evidence of a level of supervision that was required if/when s/he had behaviors with other residents and/or roommates. Record review revealed that on [DATE] Resident ID #1 was found without his/her oxygen on numerous occasions. Record review revealed the following events/incidents occurred on [DATE] thorough [DATE]: - [DATE] at approximately 5:30 PM Resident ID #2 had lined up juice and milk cups at the foot of Resident ID #1's bed. Nursing Assistant (NA), Staff D, asked Resident ID #2 to not put his/her cups on Resident ID #1's bed. Resident ID #2 responded, go f*** yourself. - [DATE] at approximately midnight Resident ID #1's oxygen concentrator was alarming. Staff D entered the room and turned the oxygen concentrator off and then back on and the concentrator stopped alarming. - [DATE] at 12:15 AM Resident ID #1's oxygen concentrator was again alarming. Staff D replaced the concentrator. - [DATE] at approximately 2:00 AM Staff D went to answer a call light, and on the way back, she checked on Resident ID #1. [His/her] oxygen was off, so I put it back on. - [DATE] at 2:30 AM- Resident ID #2 rang his/her call bell and said, this f****** [ guy/gal] is making a lot of noise. Upon observation Resident ID #1's O2 was off again. - [DATE] at 3:30 AM- Resident ID #1's call bell was ringing. Staff D asked Resident ID #2 if s/he had pressed the call light. Resident ID #2 indicated that Resident ID #1 needed help and s/he pulled the call light him/herself. At this time Staff D noted that the nasal cannula was again off. Staff D questioned Resident ID #2 and asked if s/he has been taking off Resident ID #1's oxygen. Resident ID #2 responded it's not me .It's f******* [him/her] .I have put up with [his/her] f****** noise all night I want [him/her] f****** out of here now .I'll f****** push [him/her] into the hallway myself . - [DATE] at 4:53 AM -a note authored by Staff B states, Resident upset about roommate making noise all night (roommate is a mouth breather and snores). Resident stated that [s/he] can not stand the noise [s/he] is going to push [him/her] out in the hall. Resident has been taking roommates oxygen off and stating to get [him/her] out of here. Resident has been found standing over roommate multiple times, just staring at roommate. - [DATE] at 5:15 AM- Staff B observed Resident ID #1's nasal cannula tubing off his/her nose. It was nicely rolled up at the foot Resident ID #1s feet. - [DATE] at approximately 6:15 AM- Resident ID #2 was standing over his/her roommate, Resident ID #1's nasal cannula was off again. - [DATE] at 6:34 AM- a note authored by Staff B, states in part, Resident told this writer that [s/he] was going down to get something to snack on from the vending machine. Staff member found resident in dining room taking sugar. When staff member told [him/her] that [s/he] is not supposed to be behind the double doors at this time, resident swung [his/her] cane at him. Resident refused to have [his/her] blood sugar checked this morning . - [DATE] at 7:15 AM- a note authored by Staff B, states in part, .behaviors during the night was reported to [name redacted] on call .She also stated that we should keep resident and roommate separate until then. - [DATE] at 9:22 AM Authored by Staff A, states in part, Resident noted to be cyanotic upon arrival to facility this morning. SPO2 [peripheral oxygen saturation] noted to be 90% @ [at] 2L [LPM; Liters per minute] via NC. Resident appeared to be struggling to breathe. O2 removed and resident was placed on a non-rebreather @5L. Spo2 up to 96% but slowly started to drop down to 88%. Resident sent out 911. NP notified; family notified. This writer called [acute care hospital] and report was given to ER [emergency room ] nurse . - [DATE] at 10:54 AM - a note authored by Staff B, (this note was written by Staff B after Resident ID #1 had already been transported to the hospital) states in part, Resident does not realize that removing [his/her] roommates oxygen is harmful to the roommate .Resident believed the oxygen was what was making all the loud noises .After this talk room was closely monitored, by door being left open. Staff member within could see roommate clearly from the hallway due to roommates' bed being close to door. Resident did leave unit to go to vending machine and upon return went into day room. -[DATE] at 12:57 PM - a note authored by Staff A, states in part, .told by ER nurse that resident had passed away r/t [related to] end stage COPD. Record review failed to reveal evidence that the facility provided appropriate interventions or increased supervision for Resident ID #1 and Resident ID #2 on the following dates and times when Resident ID #1 was found without his/her supplemental oxygen or when Resident ID #2 was found standing over his/her roommate and staff was concerned s/he was removing Resident ID #'1 supplemental oxygen: - [DATE] at 2:00 AM - [DATE] at 2:30 AM - [DATE] at 3:30 AM - [DATE] at 5:15 AM - [DATE] at 6:15 AM During a surveyor interview with Staff D on [DATE] at 2:20 PM she revealed that she cared for Resident ID #1 on [DATE] on the 3 PM to 11 PM shift and [DATE] on the 11 PM to 7 AM overnight shift. She indicated that at approximately 5:30 PM on [DATE] Resident ID #2 was standing at the foot of Resident ID #1's bed and was lining up juice and milk cups at the foot of the bed. Staff D indicated that when she questioned Resident ID #2 on what s/he was doing s/he replied with go f*** yourself. She indicated that at approximately 12:00 AM Resident ID #1's oxygen concentrator was alarming. She went into the room and turned off and on the concentrator and the beeping stopped. She further indicated at 12:15 AM the concentrator started alarming again and she replaced the old concentrator with a new concentrator. Staff D indicated that she went to answer a call light at approximately 2:30 AM and on her way back she noticed that the nasal cannula for Resident ID #1 was not in his/her nose. The nasal cannula was located on the side of Resident ID #2. Staff D indicated that at this time Resident ID #2 was standing at the head of Resident ID #1's bed. At 2:30 AM Resident ID #2 rang his/her call light and at that time she noticed that the nasal cannula for Resident ID #1 was laying on the bed. Staff D further indicated that at 3:30 AM Resident ID #1's nasal cannula was again off his/her nose and by his/her stomach. Staff D indicated the last time she saw Resident ID #1's nasal cannula off was at approximately 6:30 AM on [DATE] when Resident ID #2 was again standing over Resident ID #1. The surveyor questioned Staff D on if Resident ID #1 could remove his/her own oxygen and she replied, no way [s/he] could do that. During a surveyor interview on [DATE] at 8:35 AM with Staff B she revealed that she cared for Resident ID #1 on [DATE] ,d+[DATE] PM shift and [DATE] on the ,d+[DATE] overnight shift. She revealed that during the overnight shift it was reported to her by Staff D, that Resident ID #1 was noted without his/her oxygen tubing, further revealing the tubing was rolled up at the foot of Resident ID #1's bed. She further revealed that she suspected that Resident ID #2, had removed Resident ID #1's oxygen tubing as s/he was unable to remove his/her own tubing. Staff B further revealed that Resident ID #2 was observed by staff standing over Resident ID #1 during the night and that s/he was subsequently escorted out of the room in the early morning at approximately 5:15 AM. Lastly, she revealed that LPN, Staff E came in for the morning shift at approximately 7:00 AM and she reported to him that Resident ID #1 was snoring and that she was unable to administer his/her medications because she could not wake him/her. She also revealed that she told Staff E that the resident's skin was looking darker than usual. Staff E then attended to the resident. During a surveyor interview on [DATE] at 11:02 AM Staff E, revealed that on the morning of [DATE] he arrived at the facility minutes before 7:00 AM for his shift and he was alerted to Resident ID #1's room by the overnight staff due to concerns that the resident was mottled in appearance (discoloration of the skin due to a decrease in blood flow). Staff E and another nurse, Registered Nurse, Staff F, entered the resident's room to find the resident in respiratory distress, cyanotic, with an SPO2 of 91% on 2 liters of oxygen via nasal cannula. Staff E revealed the resident's respiratory distress worsened, further describing that the resident displayed agonal breathing (insufficient breathing that may sound like gasping, labored breathing, snoring, or snorting). Staff E then obtained vital signs in which he reported to the oncoming nurse assigned to care for Resident ID #1, and that she needed to call 911. Lastly, Staff E was asked by this surveyor if he had administered a nebulizer treatment (liquid medication inhaled to assist with opening the airway) to the resident when s/he was found in respiratory distress, he responded that he did not. Record review of the document titled RI EMS [Emergency Medical Services] Patient Care Report dated [DATE] with a time of 7:50 AM for Resident ID #1 revealed, EMS was dispatched to the nursing home for Resident ID #1 for difficulty breathing. Upon arrival the resident was short of breath. Staff reported SPO2 of 88% and the patient was noted to be on a nonrebreather mask at 4 liters per minute on a compressor with a deflated bag. Resident ID #1 was then switched to a nonrebreather mask at 15 liters via a portable tank and his/her SPO2 increased to 100%. The patient was then moved to a stretcher and wheeled to the rescue for transport to the hospital. The patient was administered a nebulizer treatment via aerosol mask at 6 liters. The patient was then taken into the emergency room , and [s/he] became unresponsive. Record review of Resident ID #1's hospital records dated [DATE] indicated that his/her venous blood gas levels resulted as panic with a pCO2 result of 77.9 and his/her blood pH was 7.130 (normal range is 7XXX,d+[DATE].4500), indicating the resident was in respiratory acidosis, (a condition that occurs when your lungs can't remove all the carbon dioxide produced by your body. This causes the blood and other body fluids to become too acidic. Acute respiratory acidosis occurs when carbon dioxide builds up very quickly). Further review of this document revealed that Resident ID #1 expired on [DATE] at 12:22 PM. During a surveyor interview on [DATE] at approximately 10:00 AM with the Administrator and Director of Nursing Services they were unable to provide evidence that each resident received adequate supervision to prevent the incidents that occurred between Resident ID #1 and Resident ID #2. Although the facility care planned Resident ID #2 as being very territorial, physically removing others from seats, having difficulty with roommates, complaining about noise, and has paranoia, the care plan failed to reveal evidence of a level of supervision that was required if/when s/he had behaviors with other residents and/or roommate. Additionally, the facility was aware of Resident ID #2's history with roommates, and they placed Resident ID #1, a compromised and vulnerable individual as his/her roommate. Record review failed to reveal evidence that the facility provided appropriate interventions or increased supervision for Resident ID #1 and Resident ID #2 when Resident ID #1 was found without his/her supplemental oxygen or when Resident ID #2 was found standing over his/her roommate and staff was concerned that Resident ID #2 was removing Resident ID # 1's supplemental oxygen on the following dates and times: - [DATE] at 2:00 AM - [DATE] at 2:30 AM - [DATE] at 3:30 AM - [DATE] at 5:15 AM - [DATE] at 6:15 AM Additionally, when Resident ID #2 complained about the noise and indicated s/he was going to physically remove the resident from the room on [DATE] the facility failed to intervene and provide appropriate interventions for Resident ID #1 and 2 which had the potential to cause serious injury, impairment, or death. Refer to F 600

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional and hydration status, such as usual body weight and failed to follow their policy relative to weight loss and weight gain for 2 of 9 residents reviewed, Resident ID #s 123 and 32. Findings are as follows: 1. Review of a facility policy titled, Weight Monitoring Policy dated 2/24/2017, states in part, All residents are to be weighed at least monthly so as to monitor for weight loss, to assess for underlying causes of weight loss and to intervene accordingly in a timely manner to allow for an optimal level for well-being .if the weight is +/-3 pounds from previous month, the resident is to be removed from scale and reweighed immediately .If the re-weight is accurate and there has been a significant weight loss, nursing must notify the following: physician, dietician .After the unit manager reviews the report and a weight loss has been confirmed, the resident will be placed on weekly weights. The dietician will review the weights and determine if additional intervention may need to be added . Record review revealed Resident ID #123 was admitted to the facility in December of 2022 with diagnoses including, but not limited to, dementia and type 2 diabetes mellitus. The resident's weight on admission was 170 pounds. Review of the Weights and Vitals Monitoring revealed a weight recorded on 1/1/2023 of 172.4 pounds and a weight recorded on 2/16/2023 of 149.6 pounds. This is a 22.8 pound weight loss or a 13.23% weight loss in one month, which constitutes a significant weight loss. Further record review failed to reveal evidence of a re-weight after the significant weight loss from 1/2/2023 to 2/16/2023 per facility policy. Additionally, record review failed to reveal evidence that the physician or dietician were notified until 2/23/2023 when the surveyor brought the significant weight loss to the facility's attention. During a surveyor interview on 2/23/2023 at 12:55 PM with the Director of Nursing (DON) and the [NAME] President of Operations (VPO), they were unable to provide evidence that the physician or dietician had been notified of the significant weight loss or that a reweigh had been obtained per the facility policy. During a surveyor interview on 2/23/2023 at 1:12 PM, with Nursing Assistant (NA), Staff J, she revealed that she obtained the residents weight that day and it was 150.2 pounds. During a surveyor interview on 2/24/2023 at approximately 10:00 AM with the Dietician, she revealed that she was not made aware of the resident's significant weight loss until 2/24/2023. Additionally, she revealed that she would have expected to be made aware on 2/16/2023 to be able to implement interventions. During a surveyor interview on 2/28/2023 at approximately 9:30 AM with the VPO, she acknowledged that weekly weights had not been implemented and that the facility did not follow the policy regarding a significant weight loss. 2. Record review revealed Resident ID #32 was admitted to the facility in March of 2014 with diagnoses including, but not limited to, heart failure and chronic kidney disease. Additionally, record review revealed a care plan revised on 12/27/2022 for The resident has nutritional problem or potential nutritional problem r/t [related to] leaves >25 % food uneaten at meals . with interventions including but not limited to .Monitor weight/report weight . Review of a document titled, Weights and Vitals Summary revealed a weight recorded on 1/6/2023 of 120.8 pounds and a weight recorded on 2/6/2023 of 128 pounds, which indicates a 7.1 pound or 5.9% weight gain in one month. Further record review of the physician's orders revealed an order dated 2/15/2023, that states, daily weight in the morning for CHF [congestive heart failure] monitoring. Record review failed to reveal evidence that daily weights were obtained as ordered. During a surveyor interview with the DON on 2/28/2023 at 11:50 AM, she was unable to provide evidence that daily weights were obtained from 2/16/2023 until 2/23/2023 per the physician's order. 21613

Based on record review and staff interview, it has been determined that the facility failed to ensure that the physician reviewed the resident's total program of care, including medications and treatments and adequately managed the continuity of care following hospitalization for 3 of 3 residents reviewed for physician services (Resident ID #s 4, 9, & 11). Findings are as follows: 1. Resident ID #4 was admitted to the facility in (MONTH) of 2019 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Record review revealed the resident was transferred to the hospital on [DATE] with a bleed in the upper gastrointestinal tract (organ system in the body consisting of the mouth and esophagus). The resident was re-admitted to the facility on [DATE]. Review of the Continuity of Care (C[NAME]) form revealed under medication list, continue taking these medications including but not limited to: -[MEDICATION NAME] (an oral diabetes medicine that helps control blood sugar levels) 10 milligrams (mg) by mouth two times a day -[MEDICATION NAME] (an oral diabetes medicine that helps control blood sugar levels) 1000 mg by mouth two times a day A review of the nursing readmission progress note dated 7/20/2019 at 9:55 PM revealed that all orders were verified by the on-call nurse practitioner (NP). The progress note further states the NP asked that either the attending physician or the physician assistant go over the medications when they admit the resident. Further record review reveals no evidence that the medication orders were reviewed by either the physician assistant or the physician. Review of the electronic Medication Administration Record [REDACTED]. Further record review failed to reveal evidence that a physician's orders [REDACTED]. Review of a progress note dated 7/23/2019 at 4:28 PM revealed resident was found .non-responsive to sternal rub. [MEDICATION NAME] (a medication used to raise blood sugar levels) administered and 911 called . the resident's blood sugar was 21 (normal range 70-99). The resident was transported to the hospital. Review of the hospital admission history and physical revealed, The (resident) was found at (facility) by staff to be lethargic and unresponsive .was given 1 [MEDICATION NAME] prior to EMS (emergency medical service) arrival. EMS reported blood sugar of 81. (Resident) was obtunded (slowed responses to stimulation) upon presentation here. Required 2 pushes of D50 ([MEDICATION NAME] is used as treatment of [REDACTED]. The hospital paperwork further revealed (resident) probably became hypoglycemic (low blood sugar) in the setting of being on oral antidiabetics including [MEDICATION NAME] .level of care intensive care unit. The resident was discharged from the hospital and re-admitted to the facility on [DATE]. The EMAR for (MONTH) 2019 revealed the resident received [MEDICATION NAME] 10 mg on 8/2/2019 AM, 8/3/2019 in the AM and PM and 8/4/2019 in the AM and [MEDICATION NAME] 1000 mg 8/2/2019 in the AM, 8/3/2019, 8/4/2019 in the AM and PM. Review of the EMAR revealed blood sugar levels on 8/4/2019 at 6:30 AM of 42 and at 11:30 AM of 36. Further record review revealed no evidence of interventions related to the above blood sugar readings or that the physician was notified. Review of a laboratory report of a blood draw dated 8/5/2019 revealed a blood sugar level of less than 10. A progress note dated 8/5/2019 at 8:07 AM revealed the resident had a blood sugar of 34, [MEDICATION NAME] was administered. A call was placed to the physician assistant, and they were awaiting a call back. Review of a progress note dated 8/5/2019 at 8:59 AM revealed, to discontinue [MEDICATION NAME] and hold [MEDICATION NAME] for 3 days. Further review of a progress note dated 8/5/2019 at 5:05 PM revealed the resident's blood sugar was 41, was nonresponsive and mumbling unrecognizable words. [MEDICATION NAME] was administered and the resident refused to go to the hospital. An interview was conducted with the physician on 2/25/2020 at approximately 10:00 AM. He could not recall the event that took place with the resident. He stated if the resident was placed on the two above medications after hospital discharge, he would expect blood sugar monitoring for at least a few days to make sure the resident was being monitored appropriately. 2. In review of the facility's Weight Monitoring Policy it states, All residents are to be weighed at least monthly, so as to monitor for weight loss, to assess for underlying causes of weight loss and to intervene accordingly in a timely manner to allow for an optimal level for well-being .rule out any medical reason .if re-weigh is accurate and there has been a significant weight loss nursing must notify physician, dietician .review advanced directives relative to resident's wishes for a [DEVICE] (gastrostomy tube is a feeding tube through the stomach). Record review for ID # 9 revealed the resident was admitted to the facility in (MONTH) of (YEAR) with [DIAGNOSES REDACTED]. Review of the resident's advanced directives dated 1/20/2020, signed by the resident and physician indicates the resident wishes to be a full code (all life support efforts will be utilized). Further review revealed a nutrition/dietary note dated 10/14/2019 which revealed a current weight of 116.6 pounds (lbs.) and a current body mass index (BMI, a measure of body fat based on height and weight that applies to adult men and women.) of 17.2 which is below healthy range. Further review of the Nutrition/Dietary note revealed a recommendation for appetite stimulant due to low weight/BMI and varying intake and for multivitamin with minerals. Review of the printed document of the progress note dated 10/24/2019 with the recommendation, revealed the physician reviewed, signed and documented start [MEDICATION NAME] (appetite stimulant) 7.5 milligrams (mg) PO (by mouth) at HS (bedtime). Review of the physician's orders [REDACTED]. Review of the weight monitoring documentation revealed the following weights: -10/8/2019 weight 116.6 lbs. -11/19/2019 weight 110.8 lbs. which indicates a 5% weight loss in 1 month -12/19/2020 weight 110 lbs. -1/22/2020 weight 111.2 lbs. -2/5/2020 weight 109.8 lbs. Review of a Nutrition/Dietary progress note dated 1/10/2020 revealed the resident's BMI was 16.2 which is below healthy range. Surveyor meal observation on 2/25/2020 at 11:35 AM revealed the resident's diet slip which stated bread with meals and high calorie cookie. Observation revealed no bread or high calorie cookie. The nursing assistant was interviewed at the time of the observation, she was unaware the resident was supposed to receive a high calorie cookie and she could not explain where or how to get the cookie. A telephone interview was conducted with the Registered Dietitian (RD) on 2/20/2020 at approximately 12:30 PM. She stated she was not aware of the resident's current weight of 109.8 lbs. and not aware that her recommendation for an appetite stimulant was never ordered. An interview was conducted with the physician on 2/25/2020 at approximately 12:30 PM. He stated he was familiar with the resident and was not aware of the resident's current weight and could not provide evidence that he addressed alternate means of nutrition via feeding tube, as per the policy, with the resident or the resident's representative. Additionally, review of a nurse's progress note dated 11/27/2019 stated the resident sustained [REDACTED]. The resident was sent out to the hospital for evaluation. Review of the emergency room record revealed the resident received a CT (computed tomography) scan of his/her head and neck. The results of the scan revealed fractures of the left zygomatic arch, left greater wing of the sphenoid, left frontal bone, left orbital floor and left lateral wall of the left maxillary sinus. (Indicating multiple fractures of the facial bones) Further review of the document revealed under Referral and Next steps to follow up with plastic surgeon in 1 week. An interview was conducted on 2/20/2020 at approximately 11:00 AM with the Staff E, staff member in charge of booking the medical appointments. She was not aware of the appointment and had not received any information to book the appointment. An interview with the resident's physician on 2/20/2020 at approximately 1:30 PM revealed he was not aware of the follow up with the plastic surgeon. 3. Record review of the Hospital Continuity of Care (C[NAME]) form for Resident ID #11 dated (MONTH) 2019, revealed he/she was admitted to the facility with [DIAGNOSES REDACTED]. Further record review of the C[NAME] form regarding medications stated, in part, STOP taking the following medications . -[MEDICATION NAME] ([MEDICATION NAME]) 10 milligram (mg) tablet (to treat high blood pressure) -Atorvastatin ([MEDICATION NAME]) 40 mg tablet (to reduce the risk of stroke, heart and blood vessel problems) -[MEDICATION NAME] ([MEDICATION NAME]) 2 mg tablet (to treat fluid retention and high blood pressure) -Carvedilol ([MEDICATION NAME]) 25 mg tablet (to treat high blood pressure and heart failure) -[MEDICATION NAME] ([MEDICATION NAME]) 50 mg tablet (to treat high blood pressure) -[MEDICATION NAME] (IMDUR) 60 mg ER (extended release) tablet (to treat heart conditions by relaxing and widening the blood vessels)- -Losartan ([MEDICATION NAME]) 100mg tablet (to treat high blood pressure/reduce the risk of a stroke) The C[NAME] further indicates the above medications were stopped until the resident was seen by Nephrology (relating to the kidneys) for further recommendations. The nephrology follow-up appointment was scheduled by the hospital for 1/10/2020 at 3:15 PM. A interview was conducted with the charge nurse, Staff D, on 2/25/2020 at approximately 10:00 AM in the presence of the Staff E, the staff member in charge of booking the medical appointments. Neither were aware of the follow up appointment with the Nephrologist. They were unable to provide evidence the resident attended the appointment. Review of progress notes from (MONTH) 2019 through (MONTH) 2020, regarding vital signs, revealed the following abnormal blood pressures: (normal range 120/80) -178/87 on 12/13/2019 -191/94 on 12/15/2019 -171/73 on 12/31/2019 -180/87 on 1/2/2020 -196/82 on 1/4/2020 -161/69 on 1/6/2020 -188/99 on 1/7/2020 -165/87 on 1/9/2020 -185/81 on 1/10/2020 -180/90 on 1/12/2020 -194/91 on 1/19/2020 -182/88 on 1/20/2020 -188/76 on 1/21/2020 Record review of the resident's MEDICATION ORDERS FOR [REDACTED]. Further record review failed to reveal evidence that the abnormal blood pressures were reported or that any interventions were put into place. Review of an admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental status (BIMS) of 15/15 which indicates the resident was cognitively intact. Review of a progress note written by the Nurse Practitioner (NP) dated 1/13/2020 revealed the resident was, seen by nurse for increased confusion that started yesterday, staff states that is more confused than normal, unable to recall their names like he/she use too. the nurses progress notes revealed the resident presented with confusion. Review of a progress note dated 1/21/2020 revealed, Resident alert with confusion, resident unable to identify writer remains confused. The resident was sent to the hospital for a CT scan on 1/21/2020. The resident was admitted with an Intercranial Hemorrhage (bleed in the brain). In addition, the resident was treated for [REDACTED]. The resident was also admitted for further monitoring and blood pressure control. During an interview with the resident's physician on 2/25/2020 at approximately 10:00 AM, he acknowledged that he had reviewed the blood pressures for this resident from admission until the 16th of (MONTH) 2020 and did not implement any new orders or recommendations. He further stated that he was not aware that the blood pressure medications were on hold or that the resident was not seen by the Nephrologist. During an interview with the NP for this resident, on 2/26/2020 at 11:38 AM, it was revealed that she was not aware that the resident had a follow up appointment with the Nephrologist, nor that the resident was not seen by the Nephrologist. Additionally, the NP was unaware the resident's blood pressure medications were on hold or that there were multiple elevated blood pressures. During an interview with the Medical Director, on 2/26/2020 at 9:30 AM, he stated that he would expect the NP and or the physician to have managed the elevated blood pressures here at the facility, regardless of the recommendations from the Nephrologist.

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, resulting in an actual decline in the resident's physical and mental well-being for 3 of 3 residents, Resident ID #s 4, 9, & 11. Findings are as follows: 1. Resident ID #4 was admitted to the facility in (MONTH) of 2019 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Record review revealed the resident was transferred to the hospital on [DATE] with a bleed in the upper gastrointestinal tract (organ system in the body consisting of the mouth and esophagus). The resident was readmitted to the facility on [DATE]. Review of the Continuity of Care (C[NAME]) form revealed under medication list, continue taking these medications including but not limited to: -[MEDICATION NAME] (an oral diabetes medicine that helps control blood sugar levels) 10 milligrams (mg) by mouth two times a day -[MEDICATION NAME] (an oral diabetes medicine that helps control blood sugar levels) 1000 mg by mouth two times a day A review of the nursing readmission progress note dated 7/20/2019 at 9:55 PM revealed that all orders were verified by the on-call nurse practitioner (NP). The progress note further states the NP asked that either the attending physician or the physician assistant go over the medications when they admit the resident. Further record review reveals no evidence that the medication orders were reviewed by either the physician assistant or the physician. Review of the electronic Medication Administration Record [REDACTED]. Further record review failed to reveal evidence that a physician's orders [REDACTED]. Review of a progress note dated 7/23/2019 at 4:28 PM revealed resident was found .non-responsive to sternal rub. [MEDICATION NAME] (a medication used to raise blood sugar) administered and 911 called . the resident's blood sugar was 21 (normal range 70-99). The resident was transported to the hospital. Review of the hospital admission history and physical revealed, The (resident) was found at (facility) by staff to be lethargic and unresponsive .(resident) was given 1 [MEDICATION NAME] prior to EMS (emergency medical service) arrival. EMS reported blood sugar of 81. (resident) was obtunded (slowed responses to stimulation) upon presentation here. Required 2 pushes of D50 ([MEDICATION NAME] is used as treatment of [REDACTED]. The hospital paperwork further revealed (resident) probably became hypoglycemic (low blood sugar) in the setting of being on oral antidiabetics including [MEDICATION NAME] .level of care intensive care unit. The resident was discharged from the hospital and re-admitted to the facility on [DATE]. The EMAR for (MONTH) 2019 revealed the resident received [MEDICATION NAME] 10 mg on 8/2/2019 AM, 8/3/2019 in the AM and PM and 8/4/2019 in the AM and [MEDICATION NAME] 1000 mg 8/2/2019 in the AM, 8/3/2019, 8/4/2019 in the AM and PM. Review of the EMAR revealed blood sugar levels on 8/4/2019 at 6:30 AM of 42 and at 11:30 AM of 36. Further review revealed no evidence of interventions related to the above blood sugar readings or that the physician was notified. Review of a laboratory report of a blood draw dated 8/5/2019 revealed a blood sugar level of less than 10. A progress note dated 8/5/2019 at 8:07 AM revealed the resident had a blood sugar of 34, [MEDICATION NAME] was administered. A call was placed to the physician assistant, and they were awaiting a call back. Review of a progress note dated 8/5/2019 at 8:59 AM revealed, to discontinue [MEDICATION NAME] and hold [MEDICATION NAME] for 3 days. Further review of a progress note dated 8/5/2019 at 5:05 PM revealed the resident's blood sugar was 41, was nonresponsive and mumbling unrecognizable words. [MEDICATION NAME] was administered and the resident refused to go to the hospital. An interview was conducted with the physician on 2/25/2020 at approximately 10:00 AM. He could not recall the event that took place with the resident. He stated if the resident was placed on the two above medications after hospital discharge, he would expect blood sugar monitoring for at least a few days to make sure the resident was being monitored appropriately. 2. In review of the facility's Weight Monitoring Policy it states, All residents are to be weighed at least monthly, so as to monitor for weight loss, to assess for underlying causes of weight loss and to intervene accordingly in a timely manner to allow for an optimal level for well-being .rule out any medical reason .if re-weigh is accurate and there has been a significant weight loss nursing must notify physician, dietician .review advanced directives relative to resident's wishes for a [DEVICE] (gastrostomy tube is a feeding tube through the stomach). Record review for ID #9 revealed the resident was admitted to the facility in (MONTH) of (YEAR) with [DIAGNOSES REDACTED]. Review of the resident's advanced directives dated 1/20/2020, signed by the resident and physician, indicates the resident wishes to be a full code (all life support efforts will be utilized). Further review revealed a nutrition/dietary note dated 10/14/2019 which revealed a current weight of 116.6 pounds (lbs.) and a current body mass index (BMI, a measure of body fat based on height and weight that applies to adult men and women) of 17.2 which is below healthy range. Further review of the nutrition/dietary note revealed a recommendation for appetite stimulant due to low weight/BMI and varying intake and for multivitamin with minerals. Review of the printed document of the progress note dated 10/24/2019 with the recommendation, revealed the physician reviewed, signed and documented start [MEDICATION NAME] (appetite stimulant) 7.5 milligrams (mg) PO (by mouth) at HS (bedtime). Review of the physician's orders [REDACTED]. Review of the weight monitoring documentation revealed the following weights: -10/8/2019 weight 116.6 lbs. -11/19/2019 weight 110.8 lbs. which indicates a significant weight loss of 5% in 1 month -12/19/2019 weight 110 lbs. -1/22/2020 weight 111.2 lbs. -2/5/2020 weight 109.8 lbs. Review of a nutrition/dietary progress note dated 1/10/2020 revealed the resident's BMI was 16.2 which is below healthy range. Surveyor meal observation on 2/25/2020 at 11:35 AM revealed the resident's diet slip, which stated bread with meals and high calorie cookie. Observation revealed no bread or high calorie cookie. The nursing assistant was interviewed at the time of the observation, she was unaware the resident was supposed to receive a high calorie cookie and she could not explain where or how to get the cookie. A telephone interview was conducted with the Registered Dietitian (RD) on 2/20/2020 at approximately 12:30 PM. She stated she was not aware of the resident's current weight of 109.8 lbs. and not aware that her recommendation for an appetite stimulant was never initiated. An interview was conducted with the physician on 2/25/2020 at approximately 12:30 PM. He stated he was familiar with the resident and was not aware of the resident's current weight and could not provide evidence that he addressed an alternate means of nutrition via feeding tube, as per the facility policy, with the resident or the resident's representative. Additionally, review of a nurse's progress note dated 11/27/2019 stated the resident sustained [REDACTED]. The resident was sent out to the hospital for evaluation. Review of the emergency room record revealed the resident received a CT (computed tomography) scan of his/her head and neck. The results of the scan revealed fractures of the left zygomatic arch, left greater wing of the sphenoid, left frontal bone, left orbital floor and left lateral wall of the left maxillary sinus. (Indicating multiple fractures of the facial bones) Further review of the document revealed under Referral and Next steps to follow up with plastic surgeon in 1 week. An interview was conducted on 2/20/2020 at approximately 11:00 AM with the Staff E, staff member in charge of booking the medical appointments. She was not aware of the appointment and had not received any information to book the appointment. An interview with the resident's physician on 2/20/2020 at approximately 1:30 PM revealed he was not aware of the follow up with the plastic surgeon. An interview was conducted with the Director of Nursing Services (DNS) on 2/20/2020 at approximately 2:15 PM. She was not aware of the follow up appointment and could not provide evidence that the resident was seen by a plastic surgeon. 3. Record review of the Hospital Continuity of Care (C[NAME]) form for Resident ID #11 dated (MONTH) 2019, revealed he/she was admitted to the facility with [DIAGNOSES REDACTED]. Further record review of the C[NAME] form regarding medications stated, in part, STOP taking the following medications . -[MEDICATION NAME] ([MEDICATION NAME]) 10 milligram (mg) tablet (to treat high blood pressure) -Atorvastatin ([MEDICATION NAME]) 40 mg tablet (to reduce the risk of stroke, heart and blood vessel problems) -[MEDICATION NAME] ([MEDICATION NAME]) 2 mg tablet (to treat fluid retention and high blood pressure) -Carvedilol ([MEDICATION NAME]) 25 mg tablet (to treat high blood pressure and heart failure) -[MEDICATION NAME] ([MEDICATION NAME]) 50 mg tablet (to treat high blood pressure) -[MEDICATION NAME] (IMDUR) 60 mg ER (extended release) tablet (to treat heart conditions by relaxing and widening the blood vessels) -Losartan ([MEDICATION NAME]) 100mg tablet (to treat high blood pressure/reduce the risk of a stroke) The C[NAME] further indicates the above medications were stopped until the resident was seen by Nephrology (relating to the kidneys) for further recommendations. The nephrology follow-up appointment was scheduled by the hospital for 1/10/2020 at 3:15 PM. An interview was conducted with the charge nurse, Staff D, on 2/25/2020 at approximately 10:00 AM in the presence of the Staff E, the staff member in charge of booking the medical appointments. Neither were aware of the follow up appointment with the Nephrologist. They were unable to provide evidence the resident attended the appointment. Review of progress notes from (MONTH) 2019 through (MONTH) 2020, regarding vital signs, revealed the following abnormal blood pressures: (normal range 120/80) -178/87 on 12/13/2019 -191/94 on 12/15/2019 -171/73 on 12/31/2019 -180/87 on 1/2/2020 -196/82 on 1/4/2020 -161/69 on 1/6/2020 -188/99 on 1/7/2020 -165/87 on 1/9/2020 -185/81 on 1/10/2020 -180/90 on 1/12/2020 -194/91 on 1/19/2020 -182/88 on 1/20/2020 -188/76 on 1/21/2020 Record review of the resident's MEDICATION ORDERS FOR [REDACTED]. Further record review failed to reveal evidence that the abnormal blood pressures were reported to the provider or that any interventions were put into place. Review of an admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental status (BIMS) of 15/15 which indicates the resident was cognitively intact. Review of a progress note written by the Nurse Practitioner (NP) dated 1/13/2020 revealed the resident was, seen by nurse for increased confusion that started yesterday, staff states that is more confused than normal, unable to recall their names like he use too. the nurses progress notes revealed the resident presented with confusion. Review of a progress note dated 1/21/2020 revealed, Resident alert with confusion, resident unable to identify writer remains confused. The resident was sent to the hospital for a CT scan on 1/21/2020. The resident was admitted with an Intercranial Hemorrhage (bleed in the brain). In addition, the resident was treated for [REDACTED]. The resident was also admitted for further monitoring and blood pressure control. During an interview with the resident's physician on 2/25/2020 at approximately 10:00 AM, he acknowledged that he had reviewed the blood pressures for this resident from admission until the 16th of (MONTH) 2020 and did not implement any new orders or recommendations. He further stated that he was not aware that the blood pressure medications were on hold or that the resident was not seen by the Nephrologist. During an interview with the NP for this resident, on 2/26/2020 at 11:38 AM, it was revealed that she was not aware that the resident had a follow up appointment with the Nephrologist, nor that the resident was not seen by the Nephrologist. Additionally, the NP was unaware the resident's blood pressure medications were on hold or that there were multiple elevated blood pressures. During an interview with the Medical Director, on 2/26/2020 at 9:30 AM, he stated that he would expect the NP and or the physician to have managed the elevated blood pressures here at the facility, regardless of the recommendations from the Nephrologist.

Based on record review and staff interview, it has been determined that the Medical Director failed to coordinate the medical care in the facility. The failure of the facility resulted in immediate jeopardy for F 684, F 692, and F 711. Findings are as follows: 1. As evidenced by the facility's failure to maintain acceptable parameters of nutritional status, such as usual body weight, in regards to weight loss as referenced in F-692 at level [NAME] 2. As evidenced by the facility's failure to ensure that residents receive treatment and care in accordance with professional standards of practice resulting in an actual decline in the resident's physical and mental well-being as referenced in F-684 at level [NAME] 3. As evidenced by the facility's failure to ensure that the physician reviewed the resident's total program of care, including medications and treatments, and adequately managed the continuity of care following hospitalization as referenced in F-711 at level [NAME] 4. As evidenced by the facility's failure to ensure that the medical director implements resident care policies and coordinates the medical care in the facility as referenced by F-841 at level H. 5. As evidenced by the facility's failure to ensure that each resident's drug regimen is free from unnecessary drugs when used without adequate monitoring and in the presence of adverse consequences, which indicate the dose should be reduced or discontinued, as referenced in F-757 at level [NAME]

Based on record review and staff interview, it has been determined that the facility is not administered in a manner that enabled it to utilize resources effectively and efficiently to maintain the highest practicable physical, mental and psychosocial well-being of each resident. The failure resulted in immediate jeopardy for F 684, F 692, and F 711. Findings are as follows: 1. As evidenced by the facility's failure to maintain acceptable parameters of nutritional status, such as usual body weight, in regards to weight loss as referenced in F-692 at level [NAME] 2. As evidenced by the facility's failure to ensure that residents receive treatment and care in accordance with professional standards of practice resulting in an actual decline in the resident's physical and mental well-being as referenced in F-684 at level [NAME] 3. As evidenced by the facility's failure to ensure that the physician reviewed the resident's total program of care, including medications and treatments, and adequately managed the continuity of care following hospitalization as referenced in F-711 at level [NAME] 4. As evidenced by the facility's failure to ensure that the medical director implements resident care policies and coordinates the medical care in the facility as referenced by F-841 at level H. 5. As evidenced by the facility's failure to ensure that each resident's drug regimen is free from unnecessary drugs when used without adequate monitoring and in the presence of adverse consequences, which indicate the dose should be reduced or discontinued, as referenced in F-757 at level [NAME]

Based on record review and staff interview it has been determined that the facility failed to ensure each resident's drug regimen is free from unnecessary drugs when used without adequate monitoring and in the presence of adverse consequences for 1 of 6 residents reviewed, ID # 4. Findings are as follows: 1. Resident ID #4 was admitted to the facility in (MONTH) of 2019 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Record review revealed the resident was transferred to the hospital on [DATE] with a bleed in the upper gastrointestinal tract (organ system in the body consisting of the mouth and esophagus). The resident was re-admitted to the facility on [DATE]. Review of the Continuity of Care (C[NAME]) form revealed under medication list, continue taking these medications including but not limited to: -[MEDICATION NAME] (an oral diabetes medicine that helps control blood sugar levels) 10 milligrams (mg) by mouth two times a day -[MEDICATION NAME] (an oral diabetes medicine that helps control blood sugar levels) 1000 mg by mouth two times a day A review of the nursing readmission progress note dated 7/20/2019 at 9:55 PM revealed that all orders were verified by the on-call nurse practitioner (NP). The progress note further states the NP asked that either the attending physician or the physician assistant go over the medications when they admit the resident. Further record review reveals no evidence that the medication orders were reviewed by either the physician assistant or the physician. Review of the electronic Medication Administration Record [REDACTED]. Further review failed to reveal evidence that a physician's orders [REDACTED]. Review of a laboratory report of a blood draw dated 8/5/2019 revealed a blood sugar level of less than 10 (normal range 70-99). A progress note dated 8/5/2019 at 8:07 AM revealed the resident had a blood sugar of 34, [MEDICATION NAME] administered, call placed to physician assistant awaiting call back. Review of a progress note dated 7/23/2019 at 4:28 PM revealed resident was found .non-responsive to sternal rub. [MEDICATION NAME] (a medication used to raise blood sugar) administered and 911 called . the resident's blood sugar was 21. The resident was transported to the hospital. Review of the hospital admission history and physical revealed, The (resident) was found at (facility) by staff to be lethargic and unresponsive .(resident) was given 1 [MEDICATION NAME] prior to EMS (emergency medical service) arrival. EMS reported blood sugar of 81. (resident) was obtunded (slowed responses to stimulation) upon presentation here. Required 2 pushes of D50 ([MEDICATION NAME] is used as treatment of [REDACTED]. The hospital paperwork further revealed (resident) probably became hypoglycemic (low blood sugar) in the setting of being on oral antidiabetics including [MEDICATION NAME] .level of care intensive care unit. The resident was discharged from the hospital and re-admitted to the facility on [DATE]. The EMAR for (MONTH) 2019 revealed the resident received [MEDICATION NAME] 10 mg on 8/2/2019 AM, 8/3/2019 in the AM and PM and 8/4/2019 in the AM and [MEDICATION NAME] 1000 mg 8/2/2019 in the AM, 8/3/2019, 8/4/2019 in the AM and PM. Review of the EMAR revealed blood sugar levels on 8/4/2019 at 6:30 AM of 42 and at 11:30 AM of 36. Further review revealed no evidence of interventions related to the above blood sugar readings or that the physician was notified. Review of a progress note dated 8/5/2019 at 8:59 AM revealed, to discontinue [MEDICATION NAME] and hold [MEDICATION NAME] for 3 days. Further review of a progress note dated 8/5/2019 at 5:05 PM revealed the resident's blood sugar was 41, was nonresponsive and mumbling unrecognizable words. [MEDICATION NAME] was administered and the resident refused to go to the hospital. An interview was conducted with the physician on 2/25/2020 at approximately 10:00 AM. He could not recall the event that took place with the resident. He stated if the resident was placed on the two above medications after hospital discharge, he would expect blood sugar monitoring for at least a few days to make sure the resident was being monitored appropriately.

Based on record review and staff interview, it has been determined that the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight, for 2 of 4 sample residents with weight loss, Resident ID #'s 2 and 9. In review of the facility's Weight Monitoring Policy it states, All residents are to be weighed at least monthly, so as to monitor for weight loss, to assess for underlying causes of weight loss and to intervene accordingly in a timely manner to allow for an optimal level for well-being .rule out any medical reason .if re-weigh is accurate and there has been a significant weight loss nursing must notify physician, dietician .review advanced directives relative to resident's wishes for a [DEVICE] (gastrostomy tube is a feeding tube through the stomach). 1. Record review for ID #9 revealed the resident was admitted to the facility in (MONTH) of (YEAR) with [DIAGNOSES REDACTED]. Review of the resident's advanced directives dated 1/20/2020, signed by the resident and physician indicates the resident wishes to be a full code (all life support efforts will be utilized). Further review revealed a nutrition/dietary note dated 10/14/2019 which revealed a current weight of 116.6 pounds (lbs.) and a current body mass index (BMI, a measure of body fat based on height and weight that applies to adult men and women.) of 17.2 which is below healthy range. Further review of the nutrition/dietary note revealed a recommendation for appetite stimulant due to low weight/BMI and varying intake and for multivitamin with minerals. Review of the printed document of the progress note dated 10/24/2019 with the recommendation, revealed the physician reviewed, signed and documented start [MEDICATION NAME] (appetite stimulant) 7.5 milligrams (mg) PO (by mouth) at HS (bedtime). Review of the physician's orders [REDACTED]. Review of the weight documentation revealed the following: - 1/6/2019 weight 121.6 lbs. - 3/8/2019 weight 120 lbs. - 6/6/2019 weight 119.2 lbs. -10/8/2019 weight 116.6 lbs. -11/19/2019 weight 110.8 lbs. which indicates a significant weight loss of 5% in 1 month -12/19/2019 weight 110 lbs. -1/22/2020 weight 111.2 lbs. -2/5/2020 weight 109.8 lbs. Review of a nutrition/dietary progress note dated 1/10/2020 revealed the resident's BMI was 16.2 which is below healthy range. Surveyor meal observation on 2/25/2020 at 11:35 AM revealed the resident's diet slip, which stated bread with meals and high calorie cookie. Observation revealed no bread or high calorie cookie. The nursing assistant was interviewed at the time of the observation, she was unaware the resident was supposed to receive a high calorie cookie and she could not explain where or how to get the cookie. A telephone interview was conducted with the Registered Dietitian (RD) on 2/20/2020 at approximately 12:30 PM. She stated she was not aware of the resident's current weight of 109.8 lbs. and not aware that her recommendation for an appetite stimulant was never initiated. An interview was conducted with the physician on 2/25/2020 at approximately 12:30 PM. He stated he was familiar with the resident and was not aware of the resident's current weight and could not provide evidence that he addressed alternate means of nutrition via feeding tube with the resident or the resident's representative. An interview was conducted with Resident ID #9 on 2/24/2020 at approximately 2:00 PM, s/he indicated that if offered a feeding tube s/he would be willing to accept that intervention to address weight loss. The facility failed to respond to ongoing significant loss and initiate appropriate interventions in a timely manner, allowing the resident to continue to lose weight. 2. Resident ID #2 was admitted to the facility in (MONTH) of (YEAR). The resident's [DIAGNOSES REDACTED]. Record review revealed a quarterly Minimum Data Set ((MDS) dated [DATE] revealing a significant weight loss. Review of the monthly weight record revealed the following weights: -5/6/2019 weight 187 lbs. -6/6/2019 weight 186.4 lbs. -7/8/2019 weight 182.6 lbs. -8/7/2019 weight 182.2 lbs. -9/6/2019 weight 175.6 lbs. -10/8/2019 weight 168.2 lbs. A review of the dietician's progress note dated 10/31/2019 states, in part, . weight is down 6.6 lb (4%) from (MONTH) to (MONTH) and down 11 lb (6%) over 6 months . provide diet and meds as ordered by MD. Nursing to monitor intake and enc > 50% of meals. A review of the dietician's progress note dated 11/8/2019 states, in part, . 7.4 lb (4%) weight loss in 1 month and down 21.2 lb (11%) over the past 6 months .continue to monitor for changes in weight. A review of the dietician's progress note dated 11/30/2019 states, in part, . weight is down 4.2 lbs (2.5%) and in 1 month and down 23 lbs (12%) over the past 6 months .monitor weight. Record review revealed a physician's orders [REDACTED]. -11/14/2019 weight 165.2 lbs. -11/21/2019 - no record -11/27/2019 weight 164 lbs. -12/03/2019 weight 164.4 lbs. -12/10/2019 weight 166 lbs. -12/18/2019 weight 164.4 lbs. Record review revealed the dietician's progress note dated 1/24/2020 that states, in part . reported to me he/she does not have an appetite and doesn't know why .Rec; 1. Recheck weight . This progress note was printed out with recommendations to ? appetite stimulant. Record review revealed the dietician's progress note dated 1/28/2020 that states, in part .3-day calorie count complete and indicates (resident) is taking ~873 calories per day. Current intake below needs; (resident) requires ~1500 to 1800 calories per day .Rec; 2 Report weight loss and low PO intake to MD;? if MD would want to start (resident) on appetite stimulant. Record review failed to reveal the appetite stimulant that was recommended on 1/24/2020 and again on 1/28/2020 was ever implemented. In addition, the record lacked evidence that a medical workup was completed with the exception of monitoring the resident's TSH level ([MEDICAL CONDITION] stimulating hormone-blood work to see how your [MEDICAL CONDITION] is working) to see if there were any underlying causes for the resident's loss of appetite and severe weight loss. The resident was hospitalized from [DATE] and returned to the facility on [DATE] with a new [DIAGNOSES REDACTED]. Further record review of the resident's readmission weight obtained on 2/14/2020, 7 days after readmission, revealed a weight of 163.6 lbs on 2/14/2020 and a subsequent weight of 154 lbs. on 2/19/2020. A dietary recommendation for a dietary supplement was approved to administer three times daily. The Ensure supplement was initiated on 1/21/2020. A review of the (MONTH) 2020 Medication Administration Record [REDACTED]. A review of the (MONTH) 2020 MAR indicated [REDACTED]. In review of the resident's orders, the Ensure supplement was not reinstated when readmitted to the facility on [DATE], therefore the resident had not received the supplement since 2/4/2020. Additional record review of the resident's dietary intake varied with occasional intake of 51 to 75%, occasional intake of 76 to 100%, and occasional refusals to 25% for intake. During a telephone interview with the Registered Dietician on 2/20/2020 at 2:16 PM, revealed she was unaware of the resident's current weight of 154 lbs. obtained on 2/19/2020, an additional weight loss of 9.6 lbs. In addition, she could not explain why the Ensure was not part of the resident's current orders. During a telephone interview with the resident's physician on 2/20/2020 at 2:40 PM, revealed he was unaware of the resident's severe weight loss. He was unaware of the resident's current weight of 154 lbs. as well as an additional weight loss of 9.6 lbs. The physician stated that he usually follows the recommendations from the dietician.

Based on surveyor interview and observations, it was determined that the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, for 1 of 7 residents receiving oxygen therapy resident ID#s 53. Findings are as follows: Resident ID# 53 has a physician's orders [REDACTED]. On 4/24/2018 at 10:45 AM the resident was observed lying in bed wearing a nasal cannula which was not attached to the oxygen concentrator. The flow rate on the concentrator was set at 5 liters. On 4/24/2018 at 11:00 AM, in the presence of the 3rd floor unit manager, the resident was again observed wearing the nasal cannula which was not connected to the oxygen concentrator. During interview with the unit manager at that time, she acknowledged that the tubing was not attached to the concentrator. At the request of the surveyor, the unit manager took the resident's pulse oxygen level, which registered at 82%. ( Normal blood oxygen levels are considered 95-100 percent. If the level is below 90 percent, it is considered low resulting in hypoxemia. Hypoxemia is an abnormally low level of oxygen in the blood). On 4/25/2018 at 10:30 AM, the suveyor interviewed the unit manager, who revealed that the resident's pulse oxygen level rose to 92% on 4/24/2018 after the tubing was changed and attached to the oxygen concentrator.

Based on record review and staff interview, it has been determined that the facility has failed to ensure that residents who need respiratory services receive those services for 1 of 1 sample residents who is oxygen dependent, (Resident ID # 6). Findings are as follows: Review of resident ID #6's record revealed a physician's orders [REDACTED]. Review of the resident's administration record and nurses notes from admission on 11/25/2016 thru discharge on 12/2/2016, revealed that the resident received oxygen continuously in order to maintain oxygen saturations above 92%. During a complaint investigation survey on 12/29/2016 at 11:15 AM, the surveyor interviewed the nurse (staff A) who discharged the resident on 12/2/2016 to another long term care facility. The surveyor questioned Staff A, regarding the resident being discharged without oxygen, which resulted in the resident arriving at the long term care facility to which he/she was being transferred to in respiratory distress, needing immediate interventions and having to be sent via a 911 call to an acute hospital where he/she remained for four days. Staff A stated that she is aware the resident is in need of continuous oxygen, as the resident's oxygen saturation level drops below 92% if he/ she is not receiving the oxygen. She further stated that at the time of discharge, she asked the transport person if they had oxygen in the van and he stated yes. When asked by the surveyor if Staff A had asked the transport person to get the oxygen and bring it in, so the resident could be placed in the oxygen prior to leaving the facility, she replied that she did not, as she thought the resident would be OK for a few minutes till he/she was placed in the van. Review of the resident's discharge note, written by staff A on 12/2/2016, at 13:22, states in part, discharged with her medications and personal belongings . An additional nurse's note written by staff A on 12/2/2016 at 13:28, reveals the resident was transported by an ambulance company, (company A) and the driver (driver A) was asked if he had oxygen in the van and he stated yes. During an interview with the Director of Nurses on 12/29/2016 at approximately 1:40 PM, when questioned if she had contacted the ambulance company who transported the resident, she replied that she called the ambulance company that staff A had said transferred the resident, and found out that they were not the company who transported the resident. She informed the surveyor that they do not know which ambulance company picked up the resident as they did not book the transport and think the family made the arrangements. The surveyor then spoke with the Nurse (Staff A), who also stated that she thought it was ambulance company A, because the driver was wearing a white shirt and the company they always use, the drivers wear white shirts. She further acknowledged that she does not know which ambulance company transferred the resident . On 12/30/2016, the surveyor called several ambulance companies and was able to identify the ambulance/transport company who took the resident from the facility on 12/2/2016 as Ambulance Company B. The surveyor spoke with the ambulance staff (Ambulance Staff B), who was able to identify the transfer of resident ID # 6, as being completed by their company. He informed the surveyor that the transfer was booked as a wheelchair transfer with a car van for a one way transfer from one long term care facility to another. When questioned about the use of oxygen, he stated that the chair vans do not have oxygen, and that the drivers, are not EMT's, they are transport drivers only. He again stated that the transport was booked as wheelchair transfer via van.