Every finding on record at Grandview Center

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who are appealing a discharge from the facility remain or return to the facility pending their appeal for 1 of 1 resident reviewed, Resident ID #2.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 8/4/2025, alleged that Resident ID #2 was admitted to the hospital, but Grandview would not accept the resident back. The complainant stated, I have no ramp here and no one to help me. Furthermore, the complaint alleges that an appeal was filed for an eviction notice issued on July 18th to The Executive Office of Health and Human Services, and the family was under the impression that the facility could not discharge the resident while in an active appeal. The complainant alleged that the family did not have the appropriate time to resolve the resident's Medicaid issues because it had only just been cancelled on July 9th. The resident and family were seeking legal counsel as well as trying to manage the resident's extensive medical issues.Record review revealed that Resident ID #2 was readmitted to the facility in July of 2025 with diagnoses including, but not limited to, end stage renal disease and dependence on renal dialysis (a process where a machine filters waste from the blood three times a week).Further record review revealed the resident required routine dressing changes to a right transmetatarsal amputation (removal of all or part of the forefoot) site and other diabetic ulcers.Record review revealed a recertification form dated 7/15/2025, for Resident ID #2, which states, I certify that post-hospital SNF [skilled nursing facility] care is required on behalf of the above named patient that, as a practical matter can only be provided in a SNF. The SNF care is needed on a daily basis for Skilled Rehab.Skilled Nursing.Teaching and Training.Observation & Assessment.Management & Evaluation.I estimate the additional period of SNF care will be 30 days. signed by the provider on 7/15/2025. Record review revealed a document titled [NAME] ISLAND DEPARTMENT OF HUMAN SERVICES PRE-TRANSFER OR PRE-DISCHARGE 30 DAY NOTICE dated 7/18/2025, revealed the resident was notified that s/he would be discharged from the facility in 30 days due to not having an active payer. Additionally, the document stated the resident had the right to appeal this discharge.Review of a document titled [NAME] ISLAND DEPARTMENT OF HUMAN SERVICES REQUEST FOR A HEARING revealed that on 7/28/2025 the resident was requesting an appeal of the discharge.Record review revealed the resident was discharged and admitted to an acute care hospital on 7/29/2025.Review of the hospital documentation dated 8/2/2025, revealed that the family wanted to be contacted as the family felt they could not care for Resident ID #2 at home and is requesting long term placement. The family voiced the inability to care for the resident at home as the resident needs more care than the family can provide. The family stated there are stairs to enter the home and the resident requires wheelchair at this time, and needs time for ramps to be installed. Further review of the hospital documentation revealed the resident was sent home from the hospital with his/her family on 8/6/2025.Review of the facility census on 9/9/2025 failed to reveal evidence that Resident ID #2 returned to the facility while appealing his/her discharge.During a surveyor interview with the Administrator on 9/9/2025 at 10:11 AM, she revealed that the resident was presented with a 30-day notice of discharge on [DATE] due to not having an active payor. Additionally, she acknowledged that the resident submitted an appeal of the discharge. Furthermore, she acknowledged that the resident was sent to the hospital on 7/29/2025 and did not return to the facility despite being in an active appeal of the resident's discharge. She was unable to provide evidence that the resident's right to return to the facility pending an appeal of the discharge was provided.

Based on surveyor observation and staff interview, it has been determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, relative to the main kitchen.Findings are as follows:1) Record review of The Rhode Island Food Code 2022 Edition 4.601.11 reads in part, .(A) equipment food contact surfaces .shall be clean to sight .During the initial tour of the main kitchen on 8/18/2025 at 9:15 AM, in the presence of the Food Service Director (FSD), revealed an ice machine that was noted to have black wipeable matter on the white plastic cover of the ice dispenser, located inside of the ice machine.During a surveyor interview, immediately following the above observation, the FSD acknowledged the black wipeable matter on the ice dispenser and indicated that it is cleaned monthly by the facility and quarterly by an outside company.2) Review of the Rhode Island Food Code 2018 Edition 5-202.13 states in part, An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE .may not be less than 25mm [millimeter] (1 inch) .During the initial tour of the main kitchen on 8/18/2025 at 9:15 AM, in the presence of the FSD and Maintenance Director, revealed the pipe from the ice machine was noted to be resting inside the plumbing fixture (drain) in the floor, and did not have, at a minimum, a one-inch air gap, as required.During a surveyor interview, immediately following the above observation, with the Maintenance Director, he acknowledged that there was not an air gap between the pipe and the plumbing fixture of the ice machine, as required.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to 1 of 1 resident reviewed for medication refusals, Resident ID #5.Findings are as follows:According to [NAME] (2023), ninth edition, Nursing Procedures, page 745, states in part, If a medication wasn't administered, document the reason why, any interventions taken, practitioner notification, and the patient's response to interventions.Record review revealed the resident was readmitted to the facility in July of 2014 with diagnoses including, but not limited to, type two diabetes mellitus, vascular dementia, hypertension (high blood pressure), gastro-esophageal reflux disease (GERD; a chronic condition where stomach acid flows back into the esophagus), and polymyalgia rheumatica (PMR; a condition characterized by muscle weakness and stiffness).Record review revealed a physician's order dated 7/22/2024 for aspirin, 81 milligrams (mg), with instructions to administer one tablet by mouth in the morning to prevent blood clots.Review of the August 2025 Medication Administration Record (MAR) revealed that on the following dates the resident refused his/her aspirin: 8/1, 8/2, 8/5, 8/6, 8/7, 8/8, 8/9, and 8/10/2025.Record review failed to reveal evidence that the provider was notified of the above documented refusals of aspirin.Record review revealed a physician's order dated 12/13/2023 for docusate sodium oral tablet, 100 mg, with instructions to administer one tablet by mouth, twice daily, for bowel management.Review of the August 2025 MAR revealed that on the following dates and times the resident refused his/her docusate sodium: 8/1 (AM and PM), 8/2 (AM), 8/5 (AM), 8/6 (AM), 8/7 (AM), 8/8 (AM), 8/9 (AM and PM), 8/10 (AM and PM), and 8/18/2025 (PM).Record review failed to reveal evidence that the provider was notified of the above documented refusals of the docusate sodium.Record review revealed a physician's order dated 6/12/2024 for Humalog injection solution (insulin), with instructions to administer, twice daily, based on a sliding scale of blood sugars, for diabetes mellitus.Review of the August 2025 MAR revealed that the resident refused to have his/her morning blood sugar obtained, in order to be able to have the appropriate dose of Humalog administered to him/her on 8/7/2025.Record review failed to reveal evidence that the provider was notified that the resident refused to have his/her blood sugar taken. Record review revealed a physician's order dated 6/28/2023 for isosorbide mononitrate, 30 mg, with instructions to administer one tablet, once daily, for heart rate, and to hold if the resident's systolic blood pressure (SBP; the top number in a blood pressure reading that indicates the force of blood pushing against the artery walls when your heart beats) is below 100.Review of the August 2025 MAR revealed that on the following dates the resident refused his/her isosorbide mononitrate: 8/4, 8/5, 8/7, 8/8, 8/9, 8/11, 8/13, 8/14, 8/15, 8/16, 8/17, 8/18, 8/19, and 8/20/2025.Record review failed to reveal evidence that the provider was notified of the above documented refusals of the isosorbide mononitrate.Record review revealed a physician's order dated 12/20/2022 for Lasix, 20 mg, with instructions to administer one tablet daily for edema (swelling).Review of the August 2025 MAR revealed that on the following dates the resident refused his/her Lasix: 8/4, 8/5, 8/7, 8/8, 8/9, 8/11, 8/13, 8/14, 8/15, 8/16, 8/17, 8/18, 8/19, 8/20/2025.Record review failed to reveal evidence that the provider was notified of the above documented Lasix refusals.Record review revealed a physician's order dated 7/1/2025 for lisinopril tablet, 2.5 mg, once daily, for a history of hypertension.Review of the August 2025 MAR revealed the following dates the resident refused his/her lisinopril: 8/1, 8/2, 8/5, 8/6, 8/7, 8/8, 8/9 and 8/10/2025.Record review failed to reveal evidence that the provider was notified of the above documented lisinopril refusals.Record review revealed a physician's order dated 10/9/2023 for Lopressor tablet, 12.5 mg, with instructions to administered twice daily for hypertension, and to hold if the resident's SBP is below 100 or his/her heart rate is below 60.Review of the August 2025 MAR revealed that on the following dates the resident refused his/her Lopressor: 8/1 (AM), 8/2 (AM), 8/5 (AM), 8/7 (AM), 8/9 (AM and PM), 8/10 (AM and PM), and 8/18/2025 (PM).Record review failed to reveal evidence that the provider was notified of the above documented Lopressor refusals.Record review revealed a physician's order dated 7/22/2014 for magnesium oxide tablet, 400 mg, with instructions to administer one tablet, twice daily, for magnesium supplement.Review of the August 2025 MAR revealed that on the following dates the resident refused his/her magnesium oxide: 8/1 (AM and PM), 8/2 (AM), 8/5 (AM), 8/6 (AM), 8/7 (AM), 8/8 (AM), 8/9 (AM and PM), 8/10 (AM and PM), and 8/18/2025 (PM).Record review failed to reveal evidence that the provider was notified of the above documented magnesium oxide refusals.Record review revealed a physician's order dated 11/12/2024 for Metamucil oral powder, with instructions to give 1 teaspoon by mouth, once daily, every other day, to bulk up stool.Review of the August 2025 MAR revealed that on the following dates the resident refused his/her Metamucil: 8/1, 8/5, 8/7, and 8/9/2025.Record review failed to reveal evidence that the provider was notified of the above documented Metamucil refusals.Record review revealed a physician's order dated 7/22/2014 for Prednisone tablet, 2.5 mg, with instructions to administer one tablet, by mouth in the morning, for PMR.Review of the August 2025 MAR revealed that on the following dates the resident refused his/her Prednisone: 8/1, 8/2, 8/5, 8/6, 8/7, 8/8, 8/9, and 8/10/2025.Record review failed to reveal evidence that the provider was notified of the above documented Prednisone refusals.Record review revealed a physician's order dated 10/3/2019 for Prilosec capsule delayed release, 20 mg, with instructions to administer once daily for GERD.Review of the August 2025 MAR revealed that on the following dates the resident refused his/her Prilosec: 8/4, 8/5, 8/7, 8/8, 8/9, 8/11, 8/13, 8/14, 8/15, 8/16, 8/17, 8/18, 8/19, and 8/20/2025.Record review failed to reveal evidence that the provider was notified of the above documented Prilosec refusals.Record review revealed a physician's order dated 12/13/2023 for Senna oral tablet, 8.6 mg, with instructions to administer two tablets, twice daily, for bowel management.Review of the August 2025 MAR revealed that on the following dates the resident refused his/her Senna: 8/1 (AM and PM), 8/2 (AM), 8/5 (AM), 8/6 (AM), 8/7 (AM), 8/8 (AM), 8/9 (AM and PM), 8/10 (AM and PM) and 8/18/2025.Record review failed to reveal evidence that the provider was notified of the above documented Senna refusals.Record review revealed a physician's order dated 12/15/2024 for Travoprost solution 0.004%, with instructions to administer one drop in his/her right eye, every evening, for glaucoma (a disease that can cause vision loss and blindness).Review of the August 2025 MAR revealed the resident refused his/her Travoprost on 8/9/2025.Record review failed to reveal evidence that the provider was notified of the above documented Travoprost refusal.Record review revealed a physician's order dated 8/2/2024 for Tylenol 8-hour Arthritis Pain oral tablet extended release (ER), with instructions to administer 650 mg, every 8 hours, for arthritis pain.Review of the August 2025 MAR revealed that on the following dates the resident refused his/her Tylenol: 8/1 (2:00 PM and 10:00 PM), 8/2 (2:00 PM), 8/4 (6:00 AM), 8/5 (6:00 AM and 2:00 PM), 8/6 (2:00 PM), 8/7 (6:00 AM and 2:00 PM), 8/8 (6:00 AM and 2:00 PM), 8/9 (2:00 PM), 8/10 (10:00 PM), 8/11 (6:00 AM), 8/13 (6:00 AM), 8/14 (6:00 AM), 8/15 (6:00 AM), 8/16 (6:00 AM), 8/17 (6:00 AM) 8/18 (6:00 AM and 10:00 PM), 8/19 (6:00 AM), and 8/20/2025 (6:00 AM).Record review failed to reveal evidence that the provider was notified of the above documented Tylenol refusals.During a surveyor interview on 8/20/2025 at 11:20 AM, with Certified Medication Technician (CMT), Staff A, she revealed that when a resident refuses medication, she informs the nurse of the refusal, who will then speak with the resident. She acknowledged that Resident ID #5 refuses his/her medications.During a surveyor interview on 8/20/2025 at 11:24 AM, with Registered Nurse, Staff B, she revealed that the CMT will alert the nurse when a resident refuses a medication. She further revealed that the nurse should notify the resident's physician of the medication refusal and indicated that the physician notification should be documented in a progress note or attached to a MAR note. Further, she revealed that if a resident refuses medications often, the physician will review the medications to see if any medications can be discontinued or altered.During a surveyor interview on 8/20/2025 at 12:43 PM, with the Director of Nursing Services (DNS), she revealed that if a resident refuses any medications, the physician should be notified, and the notification should be documented in a progress note. She further revealed that if a resident frequently refuses medications, a discussion will occur with the resident's physician regarding discontinuing the medications, if able. Lastly, she revealed that she was not aware of the above-mentioned medication refusals in August 2025 for Resident ID #5.During a surveyor interview on 8/20/2025 at 12:59 PM, with Nurse Practitioner, Staff C, he revealed that he was aware of some previous medication refusals, indicating the resident had been sick and was refusing his/her medications. He revealed that the resident has gone up and down with medication refusals but indicated that he thought s/he began taking his/her medications again and was not aware of the extent of his/her medication refusals.Record review revealed a progress note dated 8/20/2025 at 6:20 PM, and authored by the DNS, after this concern was brought to the facility's attention by the surveyor, which states, A call was placed to [Staff C], regarding the resident's refusal of medication. He stated that he had previously discussed with the Power of Attorney that the resident's intake would fluctuate due to [his/her] declining health, but he was unaware of the extent of [his/her] medication refusal. Upon review of the medication records, it was observed that the resident's refusal has decreased since August 10-11. This observation led him to consider that [his/her] antibiotics may have caused gastric distress, and that [his/her] current relief might enable [him/her] to take [his/her] medications. He does not wish to discontinue [his/her] medications at this time but requests certain adjustments. All 6 AM medications have been changed to 9 AM, as [s/he] consistently refuses pills at the earlier time. These medications include Tylenol 650 mg ER (now Tylenol 650 mg PO [by mouth] BID [twice daily]), Lasix 20 mg, Isosorbide, and Prilosec, all of which have been rescheduled to 9 AM.During a surveyor interview on 8/21/2025 at 11:35 AM, with the DNS, Staff C, and the Regional Clinical Nurse, they revealed that Staff C comes into the facility twice weekly to see residents, but were unable to provide evidence that Staff C or another provider were notified of the resident's frequent medication refusals in August of 2025.Review of a progress note authored by Physician, Staff D, dated 8/21/2025 at 2:32 PM, entered into the resident's medical record, after the completion of the recertification survey, revealed he was aware of the resident's medications refusals.

Based on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic, for 3 of 4 residents reviewed for antibiotic use, Resident ID #s 20, 22, and 36. Findings are as follows:According to the Centers for Disease Control and Prevention (CDC) document titled, The Core Elements of Antibiotic Stewardship for Nursing Homes states in part, Perform antibiotic 'time outs .Nursing homes should have a process in place for a review of antibiotics by the clinical team two to three days after antibiotics are initiated to answer these key questions: Does this resident have a bacterial infection that will respond to antibiotics? If so, is the resident on the most appropriate antibiotic(s), dose, and route of administration? Can the spectrum of the antibiotic be narrowed or the duration of therapy shortened (i.e., de-escalation)? Would the resident benefit from additional infectious disease/ antibiotic expertise to ensure optimal treatment of the suspected or confirmed infection . Review of a facility policy titled, Antibiotic Stewardship last revised on 12/16/2024 states in part, .Nursing will monitor the initiation of antibiotics on patients and conduct an antibiotic time out within 48-72 of antibiotic therapy to monitor response to the antibiotic and review laboratory results. Nursing will consult with the practitioner to determine if the antibiotic is to continue or if adjustments need to be made based on the findings.1. Record review revealed that Resident ID #20 was readmitted to the facility in July of 2024 with diagnoses including, but not limited to, osteomyelitis (a bone infection) and cellulitis (a bacterial infection).Record review revealed a physician's order for Cefazolin (an antibiotic) three times a day from 8/12/2025 through 8/25/2025.Record review revealed an assessment titled, Antibiotic Time Out was scheduled to be completed on 8/15/2025.Further record review failed to reveal evidence that the Antibiotic Time Out was completed.2. Record review revealed Resident ID #22 was readmitted to the facility in March of 2025 with a diagnosis including, but not limited to, osteomyelitis.Record review revealed a physician's order for Bactrim DS (an antibiotic) two times daily from 8/1/2025 through 8/11/2025.Record review revealed an assessment titled, Antibiotic Time Out was scheduled to be completed on 8/5/2025.Further record review failed to reveal evidence that the Antibiotic Time Out was completed.3. Record review revealed Resident ID #36 was admitted to the facility in August of 2023 with a diagnosis including, but not limited to, osteoarthritis.Record review revealed a physician's order for Amoxicillin (an antibiotic) two times daily from 8/14/2025 through 8/25/2025.Record review failed to reveal an antibiotic time out was completed for use of the antibiotic.During a surveyor interview on 8/20/2025 at 10:04 AM with the Infection Preventionist, she acknowledged that Resident ID #s 20, 22, and 36 did not have antibiotic timeouts completed, per the regulation or the facility policy.

Based on record review, surveyor observation, and staff interview it has been determined that the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, for 1 of 2 residents observed for wound care, Resident ID #55.Findings are as follows:Review of a facility policy titled, Wound Dressings: Aseptic last revised 2/24/2025 states in part, .Evaluate comfort level/presence of pain and treat as indicated.discard soiled dressing.cleanse or irrigate wound and peri wound gently, as ordered.Record review revealed that the resident was readmitted to the facility in May of 2023 with diagnoses including, but not limited to, a stage IV pressure ulcer (the most severe form of a pressure injury. It's characterized by a deep, open wound that extends through the skin, underlying tissue, muscle, and bone) and type II diabetes.Review of a Wound Evaluation and Summary dated 8/18/2025 revealed the resident has a stage IV pressure ulcer to his/her left lateral foot measuring 4 centimeters (cm) X 8.4 cm X 0.1 cm.Review of a care plan dated 6/30/2025 revealed an intervention to monitor for pain and medicate as needed/as ordered.Record review revealed a physician's order dated 7/25/2025 to cleanse the wound bed with Vashe wash (a wound cleanser), apply Bactroban (an antibiotic) cream to wound bed, cover with an ABD (an absorbent dressing) pad and kerlix every day.During a surveyor observation on 8/19/2025 at 8:50 AM with Licensed Practical Nurse (LPN), Staff E and Registered Nurse (RN), Staff F of the resident's wound care, the resident was observed to be screaming and swearing out in pain. Throughout the entire dressing change neither nurse stopped to assess the resident's pain or attempted to treat the resident's pain. During the observation Staff E stated that she would give the resident pain medication when she was finished with the wound care and the resident responded, Just.give it to me now. Additionally, Staff E was observed to remove a soiled ABD pad and calcium alginate (a wound treatment) was noted to be in the wound bed from the previous dressing change. Staff E applied vashe wash to the soiled calcium alginate and then began applying Bactroban to the exposed wound bed, failing to remove the calcium alginate. Continued observation revealed Staff F, who had exited the room, returned and noted the soiled calcium alginate remained in the wound as Staff E was applying the Bactroban. Staff F then removed the soiled Calcium Alginate while Staff E continued to apply the Bactroban to the wound bed. Neither Staff E nor Staff F cleansed the wound bed once the soiled Calcium Alginate had been removed.During a surveyor interview directly following the above observation with Staff E and F they acknowledged that Resident ID #55 was yelling and swearing in pain throughout the dressing change and that they did not stop to attempt to medicate him/her. Additionally, they acknowledged that they did not cleanse the wound bed once the soiled calcium alginate was removed.During a surveyor interview on 8/19/2025 at 9:34 AM with the Director of Nursing Services (DNS), she revealed she would expect the staff to stop a wound dressing to assess and treat a resident for pain if needed. Additionally, she would expect the staff to cleanse the wound bed after the removal of a soiled dressing. The DNS was unable to provide evidence that the resident was provided treatment and services, consistent with professional standards of practice.

Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for Lovenox (an anticoagulant; a blood thinning medication), Resident ID #19.Findings are as follows:Review of a facility policy titled, Medication Administration General Guidelines dated January 2025, states in part, .Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record [MAR] .Record review revealed the resident was readmitted to the facility in August of 2025 with diagnoses including, but not limited to, the long term use of anticoagulants and stroke.Review of a physician's order dated 8/11/2025 revealed to administer Coumadin (a blood thinning medication) 6 milligrams (mg) once daily for valve replacement with a goal of achieving an international normalized ratio (INR; a blood test that measures how long it takes your blood to clot) of 2.5-3.5.Review of a physician's order dated 8/11/2025 revealed to inject Enoxaparin Sodium (Lovenox) 80 mg at 8:00 AM and 8:00 PM related to a stroke. Additionally, the order indicated to discontinue the Lovenox after two days of achieving a therapeutic INR of 2.5-3.5.Further review of the Lovenox order revealed it was discontinued on 8/14/2025 at 1:29 PM.Record review revealed the resident's INR level was within or above the therapeutic range on the following dates and times:-8/12/2025 at 9:22 AM: 3.0-8/13/2025 at 10:06 AM: 3.6Review of the August 2025 MAR revealed that the resident was administered Lovenox when the order should have been discontinued on the following dates and times:-8/13 at 8:00 PM-8/14 at 8:00 AMFurther review of the August 2025 MAR revealed that Registered Nurse, Staff F, administered the Lovenox to the resident on 8/14/2025 at 8:00 AM.During a surveyor interview on 8/21/2025 at 9:28 AM with Staff F, she revealed that the resident was to have his/her Lovenox discontinued once s/he had two consecutive days of his/her INR level at therapeutic levels. She acknowledged administering the Lovenox to the resident on 8/14/2025 and revealed that she does not recall checking the resident's INR level, as the order indicates, prior to administering the Lovenox to the resident. Further, she acknowledged that she should not have administered the resident Lovenox on 8/14/2025 based on his/her INR level and the physician's order.During a surveyor interview on 8/21/2025 at 9:44 AM with the resident's provider, Staff G, she revealed that she would have expected the Lovenox order to have been discontinued once the second therapeutic INR level result was received on 8/13/2025. During a surveyor interview on 8/21/2025 at approximately 9:45 AM with the Director of Nursing Services, she acknowledged that the Lovenox order should have been discontinued prior to 8/14/2025 at 1:29 PM, and that the resident received 2 unnecessary doses of Lovenox one on the evening of 8/13/2025 and one on the morning of 8/14/2025.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality, relative to the use of borrowed medications and inaccurately documenting in the narcotic count book for 2 of 2 residents reviewed, Resident ID #s 2 and 3. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 2/10/2025, revealed, Resident ID #3 was on hospice and received an order for Lorazepam Intensol 2 milligram (mg)/milliliter (ml) 0.25 ml every four hours and 0.25 ml every hour as needed. Resident ID #3 was presenting with symptoms, and the pharmacy was unable to deliver the Lorazepam Intensol, due to the medication being on back order. Resident ID #2 had an unused bottle of Lorazepam Intensol that was borrowed by the nurses to administer to Resident ID #3. a. Record review revealed Resident ID #3 was admitted to the facility in January of 2025 with diagnoses including but not limited to, a malignant neoplasm (a cancerous tumor) of the bronchus and a secondary malignant neoplasm of the digestive organs. Record review of a hospice visit dated 2/2/2025 for Resident ID #3 revealed a recommendation for Lorazepam 2mg/ml give 0.5mg (0.25ml) sublingually (under the tongue) every 4 hours, as needed for restlessness. Record review of a progress note dated 2/3/2025 at 1:22 PM, revealed that the hospice recommendations were reviewed with and approved by the physician. Record review revealed the following physician's orders dated 2/3/2025 for Resident ID #3: -Lorazepam 2mg/ml inject 0.5 mg (0.25 ml) every 4 hours subcutaneously (under the skin) for restless/anxiety, not sublingually as recommended by the hospice provider and approved by the physician -Lorazepam 2mg/ml inject 0.25 ml subcutaneously every hour as needed for restless/anxiety, not sublingually as recommended by the hospice provider and approved by the physician. Record review of the Narcotic book documentation revealed the following: Resident ID #2 had 30 ml of Lorazepam Intensol 2mg/ml delivered by the pharmacy on 9/20/2024. On the bottom of the page, it was written that the medication was transferred to the North team 2 Narcotic book on 2/3/2025. Resident ID #3 had 15 mls of Lorazepam Intensol entered into the book on 2/3/2025 for administration. Additional review failed to reveal evidence that 30 mls Lorazepam Intensol was transferred to Resident ID #3 from Resident ID #2 or if it was received from the pharmacy. During a surveyor interview on 5/7/2025 at approximately 1:15 PM, with Registered Nurse, Staff A, she revealed that she transcribed 15 mls in error for the Lorazepam, as it was 30 mls of medication that was received from Resident ID #2. b. Record review of a facility policy titled, Medication Administration dated 1/2025, reveals in part, .Medications supplied for one resident are never administered to another resident . Record review of Resident ID #3's February 2025 Medication Administration Record revealed s/he received Resident ID #2's Lorazepam Intensol on the following dates and times: 2/3/2025 at 10:45 AM 2/3/2025 at 5:00 PM 2/3/2025 at 7:50 PM 2/3/2025 at 9:18 PM 2/4/2025 at 1:00 AM 2/4/2025 at 5:00 AM During a surveyor interview on 5/7/2025 at approximately 1:15 PM, with Staff A, she revealed that hospice had recommended that Resident ID #3 start on Lorazepam due to increased anxiety. Staff A, acknowledged that the physician's order should have been entered as sublingual. She further stated that the pharmacy was unable to fill the order, so she borrowed Resident ID #2's bottle of Lorazepam, that was unopened and not being used, for administration to Resident ID #3. She revealed that the Lorazepam was transferred from Resident ID #2 to Resident ID #3 in the Narcotic book, and it was being administered to Resident ID #3 sublingually. During a surveyor interview on 5/7/2025 at 3:15 PM with the Staff Educator, Staff B, she acknowledged that Resident ID #2's medication should not have been borrowed for Resident ID #3, and that the Narcotic book documentation was inaccurate and incomplete. Additionally, she acknowledged that the Lorazepam order was entered as subcutaneous and should have been entered as sublingual.

Based on surveyor observation, record review, staff and resident interviews, it has been determined that the facility failed to treat each resident with respect and dignity and relative to providing assistance to residents who require supervision and/or one-to-one assistance with eating for 3 of 4 residents reviewed, Residents ID #s 16, 54 and 60. Findings are as follows: 1. Record review revealed that Resident ID #16 was readmitted to the facility in May of 2024 with diagnoses including, but not limited to, osteoarthritis, anemia, and generalized muscle weakness. Record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating the resident's cognition is intact. Record review of a progress note dated 7/16/2024 revealed a hospice recommendation for one-to-one feeding assistance for all meals related to bilateral hand contractures. Review of a physician's order dated 7/30/2024 revealed one-to-one feeding assistance for all meals. During a surveyor observation on 7/30/2024 at 8:40 AM, the resident was observed with his/her breakfast tray in front of him/her without receiving one-to-one feeding assistance. Further, s/he was observed palpating around the plate with his/her right hand attempting to find the food on the plate. Additionally, at 8:55 AM, s/he was observed picking up scrambled eggs with his/her hand. A staff member entered the resident's room to provide assistance with eating at 9:03 AM, 23 minutes after the resident had his/her meal tray in front of him/her. During a surveyor observation on 7/31/2024 at approximately 8:40 AM, Resident ID #16 was observed to be eating his/her breakfast without assistance. Additionally, s/he was observed to be palpating around the plate multiple times with his/her right hand before picking up the food. A staff member entered the resident's room to provide assistance with eating at 9:02 AM, 22 minutes after the resident had his/her meal tray in front of him/her. During a surveyor observation on 7/31/2024 at 12:20 PM, the resident was observed feeding him/herself lunch and palpating around the plate before finding a piece of pizza. A staff member entered the resident's room to provide assistance with eating at 12:38 PM, 18 minutes after the resident had his/her meal tray in front of him/her. During a surveyor interview on 7/31/2024 at 12:53 AM with Physical Therapy Assistant, Staff H, she indicated that the resident requires one-to-one staff assistance because s/he can't see. During a surveyor interview on 7/31/2024 at approximately 1:35 PM with the resident, s/he revealed that s/he can't see what is on the meal tray and needs staff to help him/her. 2. Record review revealed that Resident ID #54 was admitted to the facility in February of 2024 with diagnoses including, but not limited to, anxiety disorder and mood disorder. Record review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 out of 15, indicating the resident's cognition is intact. Further review revealed the resident requires assistance with eating. Review of a physician's order dated 7/2/2024 revealed the resident requires one-to-one assistance with eating for all meals related to weight loss. During a surveyor observation on 8/1/2024 at 8:51 AM, Resident ID #54 was observed with his/her meal tray in front of him/her with the covers still on the food and drinks. A staff member entered the resident's room to provide assistance with eating at 9:05 AM, 14 minutes after the resident had his/her meal tray in front of him/her. During a surveyor interview on 8/1/2024 at 9:11 AM with Licensed Practical Nurse (LPN), Staff A, she indicated that staff usually deliver the meal trays to the residents who require assistance with eating, leave them in the room and go back sometime later when the staff have time to assist the residents. 3. Record review revealed that Resident ID #60 was admitted to the facility in April of 2024 with diagnoses including, but not limited to, abnormal weight loss, dementia, and generalized muscle weakness. Record review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 0 out of 15, indicating severe cognitive impairment. Further review revealed the resident requires extensive assistance for eating. Review of a physician's order dated 5/10/2024 indicates that the resident requires supervision for all meals. During a surveyor observation on 7/30/2024 at 8:24 AM, Resident ID #60 was observed with his/her breakfast tray in front of him/her untouched. Additional observations revealed the resident was staring at the tray and falling asleep on and off until approximately 8:40 AM. During a surveyor observation on 7/31/2024 at 8:27 AM, the resident was observed with his/her breakfast tray in front of him/her. Further observation revealed that the plate was opened and untouched with no staff members around. During a surveyor observation on 8/1/2024 at 8:33 AM, the resident's breakfast tray was observed in front of him/her, opened but untouched with no staff members around to supervise him/her as ordered. Further observations revealed the resident was looking at the plate but was not eating. At 8:59 AM, approximately 25 minutes after the resident was observed with his/her tray unattended, a staff member was observed entering the room. During a surveyor interview on 8/1/2024 at 11:20 AM with the Director of Nursing Services, she indicated that she was unaware that residents were not receiving assistance with meals as ordered in a timely manner. She further stated that the food should be kept in the warmer until they are ready to assist the resident.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to monitor and assess as outlined by the comprehensive care plan to meet professional standards of quality related to anticoagulant therapy (blood thinner) for 4 of 6 residents reviewed, Resident ID #s 9, 10, 41, and 373. Findings are as follows: 1. Record review revealed Resident ID #9 was readmitted to the facility in August of 2023 with a diagnosis including, but not limited to, atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to a stroke or other serious complications). Record review revealed a physician's order dated 8/7/2023 for Eliquis (a blood thinner that prevents or reduces the coagulation of blood, prolonging the clotting time) 5 milligrams (mg) by mouth two times a day. Review of the care plan last revised on 7/8/2024, states in part, .at risk for injury or complications related to the use of anticoagulation therapy . interventions include, but are not limited to, monitor for signs and symptoms of bleeding. Record review failed to reveal evidence that the resident was being monitored for signs and symptoms of bleeding related to the use of anticoagulation therapy as outlined by the comprehensive care plan. 2. Record review revealed Resident ID #10 was admitted to the facility in May of 2023 with a diagnosis including, but not limited to, atrial fibrillation. Record review revealed a physician's order dated 7/29/2024 for Coumadin (blood thinner) 4.5 mg by mouth in the evening for atrial fibrillation. Review of the resident's care plan last revised on 6/3/2024, states in part, .is at risk for injury or complications related to the use of anticoagulation therapy . Interventions include, but are not limited to, monitor for signs and symptoms of bleeding. Record review failed to reveal evidence that the resident was being monitored for signs and symptoms of bleeding related to the use of anticoagulation therapy as outlined by the comprehensive care plan. During an interview with Licensed Practical Nurse (LPN), Staff A, on 7/31/2024 at 8:53 AM, she revealed that the nurse should monitor for bleeding and bruising for residents that are on anticoagulation therapy. Additionally, she indicated that she would expect a physician's order to be in place to monitor residents for signs and symptoms of bleeding. Furthermore, she acknowledged that there was not an order in place to monitor for signs and symptoms of bleeding for Resident ID #s 9 and 10. 3. Record review revealed Resident ID #41 was readmitted to the facility in June of 2024 with a diagnosis including, but not limited to, atrial fibrillation. Record review revealed a physician's order dated 5/23/2024 for Eliquis 5 mg by mouth two times a day for atrial fibrillation. Review of the resident's care plan last revised on 6/19/2024, states in part, .is at risk for injury or complications related to the use of anticoagulation therapy . Interventions include, but are not limited to, monitor for signs and symptoms of bleeding. Record review failed to reveal evidence that the resident was being monitored for signs and symptoms of bleeding related to the use of anticoagulation therapy as outlined by the comprehensive care plan. 4. Record review revealed Resident ID #373 was admitted to the facility in July of 2024 with a diagnosis including, but not limited to, history of venous thrombosis and embolism (a blood clot that blocks the flow of blood through your veins or that can travel through the veins to the lungs). Record review revealed a physician's order dated 7/20/2024 for Xarelto (blood thinner) 20 mg by mouth in the evening. Review of the resident's care plan initiated on 7/21/2024, states in part, .is at risk for injury or complications related to the use of anticoagulation therapy . Interventions include, but are not limited to, monitor for signs and symptoms of bleeding. Record review failed to reveal evidence that the resident was being monitored for signs and symptoms of bleeding related to the use of anticoagulation therapy as outlined by the comprehensive care plan. During a surveyor interview with LPN, Staff B on 7/31/2024 at 10:19 AM, she was unable to provide evidence that Resident ID's 41 and 373 were being monitored related to the use of anticoagulation therapy. During a surveyor interview with the Lead Clinical Specialist, and in the presence of the Director of Nursing Services (DNS) on 7/31/2024 at 11:35 AM, he revealed that for residents receiving anticoagulant therapy the expectation would be that the nurse would monitor for signs and symptoms of bleeding. He further explained that the order would be generated to the treatment administration record (TAR) from the care plan and nurses would sign as completed. He further acknowledged that there was no order in place to monitor residents for signs and symptoms of bruising and bleeding.

Based on surveyor observation, record review, staff and resident representative interviews, it has been determined that the facility failed to ensure that a resident receives proper treatment to maintain hearing abilities for 1 of 1 resident reviewed for hearing concerns, Resident ID #10. Findings are as follows: Record review revealed the resident was admitted to the facility in May of 2023 with diagnoses including, but not limited to, diabetes mellitus type 2 and chronic obstructive pulmonary disease. Record review of a care plan dated 6/1/2023 revealed the resident has impaired communication as evidenced by being hard of hearing. Further record review revealed an intervention for an ears, nose, and throat (ENT) specialist or audiologist (a health-care professional who evaluates, diagnoses, treats, and manages hearing loss) consult to evaluate new hearing loss or progression of deteriorating hearing loss. During a surveyor interview on 7/30/2024 at 1:32 PM with the resident's family member, s/he indicated that the resident has difficulty hearing and increased hearing loss which causes the resident frustration. S/he further indicated that the resident had an appointment for ear wax removal in November of 2023, however, the appointment was cancelled and the facility had not followed up. Record review of the progress notes revealed the resident's family member was concerned with the resident's difficulty hearing in September of 2023. Further review revealed an appointment was scheduled for ear wax removal on 11/16/2023. Additional review revealed that appointment was cancelled and had not been rescheduled. During the following surveyor observations, the resident had difficulty hearing the surveyor as evidenced by the resident pointing and cupping his/her ears: -7/29/2024 at 10:50 AM -7/30/2024 at 1:32 PM -7/31/2024 at 9:36 AM During a surveyor interview on 7/31/2024 at 9:40 AM with Licensed Practical Nurse, Staff A, she acknowledged that the resident has difficulty hearing and indicated that an appointment was made for ear wax removal and cancelled in November of 2023. She could not provide evidence that any follow up or additional interventions were put into place after the appointment had been cancelled. During a surveyor interview on 7/31/2024 at 9:43 AM with the Director of Nursing Services, she indicated that she would expect the facility to follow up with the resident's hearing loss. Additionally, she could not provide evidence that any interventions had been put into place since the appointment had been cancelled in November of 2023. During a surveyor interview on 7/31/2024 at 10:06 AM with Nurse Practitioner, Staff C, he indicated that he would expect the resident's hearing difficulty to be addressed.

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 for oxygen use, Resident ID #s 5 and 10. Findings are as follows: 1. Record review revealed that Resident ID #5 was admitted to the facility in November of 2022 with diagnoses including, but not limited to, chronic obstructive pulmonary disease and chronic respiratory failure with acute exacerbation. Record review revealed a physician's order dated 5/25/2024 for oxygen at 2 liters/minute (L/M) via nasal cannula. Change oxygen tubing weekly and label each component with date and initials. During surveyor observations on the following dates and times failed to reveal evidence that the resident's oxygen tubing was labeled with a date: - 7/29/2024 10:29 AM - 7/31/2024 1:48 PM During a surveyor interview with Licensed Practical Nurse (LPN), Staff A, on 7/31/2024 at 1:50 PM, she acknowledged that the above resident's oxygen tubing was not dated per the facility policy. 2. Record review revealed that Resident ID #10 was admitted to the facility in May of 2023 with a diagnosis including, but not limited to, chronic obstructive pulmonary disease. Record review revealed a physician's order dated 5/11/2023 for oxygen at 2 L/M via nasal cannula at bedtime for comfort and remove per schedule. Change oxygen tubing weekly and label each component with date and initials. During surveyor observations on the following dates and times failed to reveal evidence that the resident's oxygen tubing was labeled with a date: - 7/29/2024 at 10:50 AM - 7/30/2024 at 8:38 AM - 7/31/2024 at 9:02 AM - 7/31/2024 at 1:40 PM During a surveyor observation on 7/31/2024 at 1:40 PM, the resident's prongs on the nasal cannula were observed to be discolored and yellow. Further observation revealed the oxygen tubing bag was dated 5/28 and 6/30. During a surveyor interview on 7/31/2024 at 1:41 PM with Staff A, she acknowledged that the Resident ID #10's oxygen tubing was not dated, that the prongs on the nasal cannula were discolored, and the tubing bag was dated 5/28 and 6/30. During a surveyor interview on 7/31/2024 at 2:00 PM with the Director of Nursing Services, she revealed that the oxygen tubing should be changed every Thursday and should be dated. Cross reference F 867

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed relative to medication administration with parameters, Resident ID #20. Findings are as follows: Record review revealed the resident was readmitted to the facility in November of 2023 with diagnoses including, but not limited to, hypertension (high blood pressure), heart murmur (abnormal heart sound), and dementia. Record review revealed a physician's order dated 11/27/2019 for Losartan potassium 25 milligrams (mg) by mouth daily for hypertension. Hold for systolic blood pressure (the pressure in the arteries when the heart beats and pumps blood out, the top number of a standard blood pressure reading) less than 110. Record review revealed a pharmacy consultation report dated 3/18/2024 through 4/1/2024, which indicated the importance of holding the medication within the parameters ordered. Additionally, the document revealed that staff were educated related to the medication parameters as of 4/2/2024. Record review of the resident's May, June, and July 2024 Medication Administration Records revealed that the medication was administered when the systolic blood pressure was less than 110: - 5 of 31 opportunities in May of 2024 - 6 of 30 opportunities in June of 2024 - 9 of 30 opportunities in July of 2024 During a surveyor interview on 7/31/2024 at approximately 11:30 AM with the Director of Nursing Services, she acknowledged that the medication had been administered outside of the ordered parameters.

Based on surveyor observation, record review and staff interview, it has been determined that the facility has failed to measure success and track performance of Quality Assurance and Performance Improvement (QAPI) actions to ensure that improvements are realized and sustained relative to changing and dating oxygen tubing. Findings are as follows: Record review of the QAPI plan and meeting minutes from January 2024 to July 2024 revealed changing and dating oxygen tubing per facility policy was a problem area that required improvement. Record review of a facility document titled, Oxygen Audit with a start date of 1/18/2024, states in part, .oxygen tubing and filters changed on Thursdays per policy . During surveyor observations from 7/29/2024 through 7/31/2024, it was revealed that 2 of 3 residents reviewed for oxygen therapy had oxygen tubing that had not been dated as ordered and were not identified by the QA process or ongoing audits. During a surveyor interview on 8/1/2024 at 10:45 AM with Lead Clinical Specialist he could not provide evidence that the facility successfully implemented a program for monitoring and evaluating oxygen orders. Cross reference F 695 46118

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide an ongoing program to support a resident in their choice of activities designed to meet the interests of and support the well-being of each resident, based on the comprehensive assessment, care plan and preferences for 1 of 1 resident reviewed for activities who is non English speaking, Resident ID #27. Findings are as follows: Record review revealed the resident was readmitted to the facility in October of 2020 with diagnoses including, but not limited to, major depressive disorder, adjustment disorder, and dementia with agitation. Review of a Minimum Data Set (MDS) assessment dated [DATE], revealed the resident is dependent on staff for all care needs. Review of a care plan dated 4/27/2023, revealed the resident expresses interest in leisure activities with interventions including, but not limited to, providing the resident with magazines, books, materials related to Europe/[NAME]/Spain, Portuguese recipes, spirituality, and to highlight opportunities to participate in music. Further review revealed a care plan dated 11/15/2023, which states in part, the resident .will have opportunities to make decisions/choices .for self-directed involvement in meaningful activities .Encourage and facilitate .activity preferences by offering the chronicle in Spanish/Portuguese, pet visits and spirituality . During surveyor observations on multiple occasions of group activities being conducted from 7/29/2024 through 8/1/2024, this resident was not in attendance. During the following surveyor observations, the resident was awake in his/her room, without a T.V., radio, reading material, or any other activitt: -7/29/2024 at 10:05 AM -7/30/2024 at 11:38 AM -7/31/2024 at 9:03 AM - 8/1/2024 at 8:45 AM During a surveyor interview on 8/1/2024 at 8:45 AM with Licensed Practical Nurse, Staff A, she acknowledged that the resident did not have any activities provided at that time and that there was not a T.V., radio, or reading material in his/her room. Additionally, she was unaware of the resident's activity preferences or if any activities were regularly provided to the resident. During a surveyor interview on 8/1/2024 at 9:17 AM with the Recreational Director she indicated that the resident enjoys singing and praying. Additionally, she acknowledged that activities had not been provided to the resident in accordance with the plan of care. During a surveyor interview on 8/1/2024 at 10:34 AM with the Director of Nursing Services, she indicated that she was unaware that the resident did not have a T.V., radio, or reading materials in his/her room. Additionally, she indicated that she would expect activities to be provided to the resident.

Based on surveyor observation, record review, resident and staff interviews, it has been determined that the facility failed to provide adequate supervision to prevent an accident hazard for 1 of 1 resident reviewed who requires the assistance of two staff for transfers with a gait belt, Resident ID #9. Findings are as follows: Record review revealed the resident was originally admitted to the facility in April of 2019, with diagnoses including, but not limited to, hemiplegia and hemiparesis following a cerebral infarction (paralysis and weakness to one side of the body following a stroke), unsteadiness on the feet, and abnormality of gait (walking) and mobility. Record review of the Minimum Data Set (MDS), Optional State Assessment, dated 6/23/2024, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident is cognitively intact. Additionally, the MDS revealed that the resident required extensive assistance of 2 people with transfers. Review of a care plan dated 8/15/2019 revealed the resident is at risk for the decreased ability to perform activities of daily living (ADLs) including transfers. Further review revealed an intervention dated 10/23/2023 that the resident required 2 people for all transfers with a gait belt every shift to prevent falls due to weakness. Record review revealed a physician's order dated 10/29/2023 that the resident requires two staff members to transfer with a gait belt every shift to prevent falls due to weakness. During a surveyor interview on 7/29/2024 at 11:02 AM with the resident, s/he indicated that s/he requires the assistance of 2 staff members to transfer out of bed, however, s/he often feels unsafe because they frequently transfer him/her with only 1 staff member. During a surveyor observation on 8/1/2024 at 10:06 AM, a Nursing Assistant (NA), Staff D, transferred the resident out of bed and into a wheelchair without the assistance of a second staff member. During a surveyor interview on 8/1/2024 at 10:15 AM with NA, Staff D, she acknowledged that she transferred the resident by herself. Additionally, she indicated that the resident only requires the assistance of 2 staff members sometimes if s/he is weak and that she frequently transfers the resident by herself, including the day before. During a surveyor interview on 8/1/2024 at 10:19 AM with Licensed Practical Nurse, Staff A, she indicated that the resident is transferred with the assistance of only 1 staff member at times. Additionally, she acknowledged that the resident has an active care plan and physician's order in place for the assistance of 2 staff members for transfers. During a surveyor interview on 8/1/2024 at 10:32 AM with the Director of Nursing Services, she indicated that the resident should be transferred with the assistance of 2 staff members as ordered.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who are trauma survivors receive trauma informed care in accordance with professional standards of practice and accounting for the resident's experiences and preferences for 1 of 1 resident reviewed with post-traumatic stress disorder (PTSD, a health condition triggered by a terrifying event causing flashbacks and nightmares), Resident ID #54. Findings are as follows: Record review revealed the resident was admitted to the facility in February of 2024, with diagnoses including, but not limited to, PTSD and anxiety disorder. Review of the care plan dated 4/9/2024, revealed the resident has a diagnosis of a mood disorder related to PTSD. Further review revealed the resident .will be appropriately evaluated and re-evaluated for specialized services as needed and per state requirements .will receive appropriate specialized services to attain or maintain [his/her] highest practicable psychological, physical, functional, and psychosocial well-being . Additional review revealed the resident exhibits, or is at risk for, distressed or fluctuating mood symptoms related to a psychiatric mood disorder. Record review failed to reveal evidence that a Trauma Informed Care evaluation was completed to identify triggers related to PTSD. During a surveyor interview on 8/1/2024 at 10:42 AM with the Director of Nursing Services and the Lead Clinical Specialist, they were unable to provide evidence that a trauma informed care assessment had been completed since the resident was admitted to the facility. Additionally, they acknowledged that an assessment needs to be completed to identify triggers for PTSD. 46118

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide special adaptive eating equipment and utensils for a resident who requires a divided lip plate, Resident ID #9. Findings are as follows: Record review revealed the resident was admitted to the facility in April of 2019 with diagnoses including, but are not limited to, hemiplegia (paralysis of partial or total body function), hemiparesis (one sided weakness following a stroke), and muscle weakness. Record review revealed a care plan dated 8/15/2019 indicating the resident has a self-care performance deficit related to having a one sided weakness with interventions including, but not limited to, maintaining the highest capable level of his/her self-care and the use of a divided lip plate and built-up utensils for self-feeding. Record review of the diet slip revealed the resident was to be provided with a divided lip plate for all meals. During surveyor observations on the following dates and times, the resident was observed without a divided lip plate at meals: -7/30/2024 at 8:31 AM -7/31/2024 at 8:42 AM -7/31/2024 at 12:05 PM During a surveyor interview on 7/31/2024 at 12:11 PM with Nursing Assistant, Staff E, she indicated that she was unaware that the resident should be provided with a divided lip plate and that she had not observed the resident's meals served on a divided lip plate in the past. During a surveyor interview on 7/31/2024 at 12:13 PM with Licensed Practical Nurse, Staff A, she acknowledged that the resident should be provided with a divided lip plate as indicated on the diet slip. During a surveyor interview on 7/31/2024 at 12:19 PM with the Director of Nursing Services, she indicated that she would expect that the resident would be provided with a divided lip plate for all meals.

Based on record review, surveyor observation and staff interview, it has been determined that the facility failed to ensure that food is served, in accordance with professional standards for food service safety, relative to the lunch meal service. Findings are as follows: Record review of the Rhode Island Food Code 2018 Edition 3-501.16 reads in part, Time/Temperature Control for Safety Food, Hot and Cold Holding indicates that cold food shall be maintained at less than or at 5 degrees Celsius/41 degrees Fahrenheit. During a surveyor observation on 8/3/2023 at approximately 11:50 AM of the lunch meal, an egg salad sandwich had a cold holding temperature of 49.1 degrees Fahrenheit. An additional surveyor observation of the lunch meal on the South nursing unit on 8/3/2023 at approximately 12:05 PM, the fat free milk had a cold holding temperature of 47.8 degrees Fahrenheit. During a surveyor interview with the Food Service Director on 8/3/2023 at approximately 12:30 PM, she acknowledged the cold holding temperatures were not within the acceptable temperature range.

45263 Based on record review and staff interview, it has been determined that the facility failed to develop and implement a baseline care plan within 48 hours of admission, for identified communication concerns and instructions needed to provide effective and person-centered care, for 1 of 1 residents reviewed for baseline care plans, Resident ID #62. Findings are as follows: Record review revealed the resident was admitted to the facility in July of 2023 following a hospitalization related to a pathological (caused by a physical disease) fracture of the left femur (thigh). Record review of the Minimum Data Set (MDS) dated [DATE] revealed, s/he was assessed as needing or wanting an interpreter to communicate with a doctor or healthcare staff member. His/her preferred language is Creole. Record review of the baseline care plan initiated on July 21, 2023 failed to reveal evidence that a care plan was developed to assist the resident with communication to a doctor or a healthcare staff member. During a surveyor observation and interview with the resident on 8/1/2023 at approximately 12:55 PM, s/he was speaking Creole when interviewed. The interview was being interpreted by the resident's family member. During a surveyor interview on 8/4/2023 at approximately 8:45 AM with Licensed Practical Nurse, Staff A, she revealed the resident only speaks Creole. During a surveyor interview on 8/4/2023 at approximately 9:55 AM with the Director of Nursing Services, he acknowledged the resident speaks Creole and was unable to provide evidence that a baseline care plan was developed for communication.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to physician's orders for 1 of 4 residents reviewed for supplemental oxygen use, Resident ID #12. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 states: The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review revealed the resident was readmitted to the facility in October of 2022 with diagnoses including, but not limited to, asthma and dependence on supplemental oxygen. Record review revealed a physician's order dated 10/24/2022 for oxygen at 2 liters per minute via nasal cannula (medical device to provide supplemental oxygen therapy) to be used continuously. Review of the care plan revealed the resident is at risk for respiratory complications related to congestive heart failure with an intervention including, but not limited to, oxygen as ordered. During surveyor observations the resident was observed without oxygen being used on the following dates and times: - 8/1/2023 at 10:24 AM - 8/1/2023 at 11:59 AM - 8/2/2023 at 9:49 AM - 8/2/2023 at 2:27 PM During a surveyor interview on 8/2/2023 at approximately 2:30 PM with Registered Nurse, Staff B, she acknowledged that the resident was not using oxygen continuously, as ordered. During a surveyor interview on 8/2/2023 at approximately 2:40 PM with the Director of Nursing Services and the Administrator, they were unable to provide evidence that the oxygen order was followed.

Based on record review and staff interview, it has been determined that facility failed to ensure that residents are free from any significant medication errors for 1 of 1 diabetic resident reviewed, Resident ID #1, who received insulin when his/her blood glucose level was 45 MG/DL (milligrams/deciliter; normal blood glucose levels for diabetics are between 80 and 130 MG/DL per the Centers for Disease Control). Findings are as follows: Record review of a community reported complaint sent to the Rhode Island Department of Health on 4/21/2023 alleges that Resident ID #1 was hospitalized for a very low blood sugar which was in the 20's upon arrival to the hospital. According to Lippincott: Manual of Nursing Practice, 2006, .The nurse should be knowledgeable about the type of insulin and/or diabetic agent, with regards to onset, peak and duration. Hypoglycemia- a blood glucose less than 50 MG/DL and nursing assessment includes: mental status changes, vital signs-noting, tachycardia, respiratory pattern, skin inspection-pallor [an unhealthy pale appearance], diaphoresis [excessive sweating], and tremors or fine motor loss . Record review of the facility policy titled Hypoglycemia Protocol dated 12/1/2006 states in part, .Perform fingerstick blood glucose measurement. - If less than 70 or physician ordered low parameter, immediately administer rapidly absorbed simple carbohydrate such as 4 oz. [ounces] juice or 5-6 oz. regular soda pop or tube of glucose gel [product taken orally to treat hypolgycemia] . - Remain with resident and monitor vital signs - Repeat resident blood glucose measurement in 10-15 minutes - If below 70, repeat juice and blood glucose measurement 10-15 minutes after juice administration. - Hold all diabetic medications, including insulin and oral meds [medications]. - Notify physician. Obtain specific follow-up orders regarding diabetic medications and glucose monitoring . Record review revealed the resident was admitted to the facility in April of 2023, with a diagnosis including, but not limited to, type 2 diabetes mellitus with hyperglycemia (an excess of glucose in the bloodstream). Record review revealed a physician's order dated 4/7/2023 for Lantus (a long-acting insulin in which the effects can last up to 24 hours) Inject 20 units at bedtime for diabetes at 8:00 PM with blood glucose monitoring at the time of the insulin administration. Record review of the Blood Sugar Summary indicated that the resident's blood glucose level on 4/16/2023 at 10:26 PM was 45 MG/DL. Record review of the April 2023 Medication Administration Record (MAR) revealed that the Lantus was administered to the resident whose blood glucose level was 45 MG/DL on 4/16/2023 by Licensed Practical Nurse, Staff A. Record review of a progress note dated 4/17/2023 at 12:37 AM authored by Staff A, revealed that at bedtime, the resident's blood glucose level was 49 MG/DL and the resident was drowsy, but alert. The progress note further revealed that glucose gel was given, but s/he vomited his/her medications and the glucose gel. Furthermore, Staff A proceeded to give food items to the resident, who consumed 4 cookies and 8 oz. of milk, and upon recheck, his/her blood glucose level was 59 MG/DL. Additional review of the progress note dated 4/17/2023, states in part, that the physician was, notified of events, new order hold Lantus tonight and administer Lantus 10 units x's [times] 1. The progress note further indicated at 11:00 PM, his/her blood glucose level was 59 MG/DL. Further record review of the April 2023 MAR failed to reveal evidence of a physician's order for Lantus 10 units or that glucose gel was administered to the resident. Record review of a progress note dated 4/17/2023 at 3:25 AM authored by Registered Nurse, Staff B, states in part, Resident's Blood sugar continued to run in the 50's, [s/he] was given Glucagon [an injectable emergency medication used to treat severe low blood glucose levels] @ [at] 1am which increased [his/her] BS [blood sugar] to 67, when sugar was checked again 15minutes later, [his/her] BS had dropped back down to 59, resident was given Chocolate pudding and milk, Which [s/he] had vomited up. Residents BS was still in the 50's. [S/he] was given a second glucagon [injection] at 1:30am, Blood sugar went up to 69. Residents BS dropped back down to 55, resident was sent out via 911 per [Medical Director's] orders . Record review failed to reveal evidence that the facility's hypoglycemic protocol policy was followed including, but not limited to, holding all diabetic medications, including insulin and monitoring vital signs. Record review of the resident's hospital documentation dated 4/17/2023 at 4:25 AM stated in part .patient's BS 29 [MG/DL]. Given amp [ampule] of dextrose [intravenous medication to treat severely hypoglycemic residents] at this time . During surveyor interviews on 4/26/2023 at 11:06 AM and 4/28/2023 at 12:41 PM with Staff A, she acknowledged that on 4/16/2023 the resident's blood glucose level at bedtime was 45 MG/DL. She indicated that she administered 10 units of Lantus to the resident instead of the ordered 20 units. Additionally, she was unable to explain why the MAR reflected that she administered 20 units of Lantus when she indicated she only gave 10 units of Lantus to the resident. Furthermore, Staff A acknowledged that she did not call the physician back when the resident's blood glucose continued to decrease, nor did she monitor his/her vital signs per the facility policy. Additionally, she was unable to explain why she did not follow the facility's hypoglycemic protocol policy or why she did not document the glucose gel on the MAR that she indicated was administered to the resident. During a surveyor interview on 4/26/2023 at approximately 1:00 PM with the Medical Director, he revealed that he did not receive a phone call on 4/16/2023 from Staff A concerning the resident's low blood glucose level. Additionally, he revealed that he did not give Staff A instructions to administer 10 units of insulin with a blood glucose level of 45 MG/DL. He further revealed that he did speak to Staff B on 4/17/2023 at approximately 3:25 AM and gave her orders to send the resident to the hospital. During a surveyor interview on 5/1/2023 at approximately 10:30 AM with the Director of Nursing Services and the Administrator, they were unable to explain why Staff A administered insulin to the resident whose blood glucose level was 45 MG/DL or why she did not follow the facility's hypoglycemic protocol policy.