Every finding on record at Greenwood Operations DBA Greenwood Center

Based on surveyor observation, record review, and staff interview, the facility failed to prepare, serve, and distribute food in accordance with professional standards for food service safety relative to the main kitchen. Additionally, the facility failed to have a certified food protection manager available during the preparation of the evening meals for 6 of 9 days reviewed.Findings are as follows:1. Review of the Food and Drug Administration (FDA) Food Code, 2022 Edition, section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, states in part, .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.During a surveyor observation during the initial kitchen tour, in the presence of the Food Service Director (FSD) on 6/23/2026 at 9:50 AM, the cooling fans in the walk-in refrigerator were observed to have a visible accumulation of dust.During a surveyor interview with the FSD immediately following the above observation, he acknowledged that the fans were dirty and needed to be cleaned.2. Review of the FDA Food Code, 2022 Edition, section 2-102.12, Certified Food Protection Manager, states in part, (A) The person in charge shall be a certified food protection manager who has shown proficiency of required information through passing a test that is part of an accredited program .Additional review of the FDA Food Code, 2022 Edition, section 2-102.20, Food Protection Manager Certification, states in part, (A) A person in charge who demonstrates knowledge by being a food protection manager that is certified by a food protection manager certification program that is evaluated and listed by a Conference for Food Protection-recognized accrediting agency .Record review failed to reveal evidence that Cook, Staff A is a Certified Food Protection Manager (CFPM).Record review failed to reveal evidence that a CFPM was working in the kitchen during its hours of operation on the following dates and times:6/16/2026, after 4:00 PM6/17/2026, after 1:00 PM6/18/2026, after 1:30 PM6/19/2026, after 1:30 PM6/20/2026, after 1:00 PM6/21/2026, after 2:00 PMDuring a surveyor interview with the FSD on 6/23/2026 at 10:10 AM, he revealed that Cook, Staff A has been working as the primary evening cook since his other cook went out on leave. Additionally, he acknowledged that she is not a current CFPM.During a subsequent surveyor interview with the FSD and Regional FSD on 6/24/2026 at 11:35 AM, they were unable to provide evidence that a CFPM was on site during hours of food preparation and serving on the above dates and times.

Based on clinical record review, surveyor observation, and staff interviews, 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, relative to staff wearing the appropriate personal protective equipment (PPE) for 1 of 1 resident observed on standard/contact precautions (CP; an infection control measure used in healthcare settings to prevent the spread of germs that can be transmitted by direct or indirect contact with a resident or their environment), who was suspected of having Clostridioides difficile (C. diff; a bacterium that can cause life-threatening diarrhea), Resident ID #91 and for 1 of 1 resident observed on 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) that was being transferred by staff, Resident ID #55.Findings are as follows: 1. Review of a facility policy titled Contact Precaution, last revised 10/24/2022, states in part, In addition to Standard Precautions, Contact Precautions will be used for diseases transmitted by direct of indirect contact with the resident/patient.or the patient's environment (e.g., C. difficile.).PROCESS.Place Contact Precautions sign on door.Instruct staff, patient and their representative, and visitors regarding Precautions and the use of personal protective equipment (PPE).Staff must use barrier precautions before or upon entering the room. PPE must be worn before contact with patient or the patient's environment.Perform proper hand hygiene.as indicated by Precaution sign.Wear gown and gloves.Before exiting the room, remove and bag gown and gloves and wash hands upon exiting room.Record review revealed Resident ID #91 was admitted to the facility in May of 2026 with a diagnosis including, but not limited to, Parkinson's disease.During a surveyor observation during the initial tour of the facility on 6/23/2026 at 9:42 AM, of Resident ID #91's room revealed a bin of PPE and signage posted at his/her doorway which states in part, STANDARD plus CONTACT PRECAUTIONS TO PREVENT THE SPREAD OF INFECTION. Please see the Nurse before entering the patient's room. Further review of the signage states in part, Perform Hand Hygiene BEFORE and AFTER patient contact, contact with environment, [and] after removal of PPE between each resident contact. Wear Gloves upon entering this room; remove prior to exiting and discard. Wear Gown upon entering this room; remove prior to exiting and discard.During a surveyor interview on 6/23/2026 at 9:45 AM, with Registered Nurse (RN), Staff C, when asked about the signage posted outside Resident ID #91's room, she stated that the resident is no longer infected and is only on EBP because s/he has a urinary catheter, although the signage indicated the resident was on CP.Review of a progress note dated 6/23/2026 at 9:19 AM states in part, .[family member] reports [s/he] was hoping C. diff test results would [be] back.During a surveyor observation on 6/23/2026 at approximately 12:00 PM of the lunch meal, revealed the following:- At 12:22 PM, Nursing Assistant (NA), Staff B, entered Resident ID #91's room without wearing any PPE, dropped off a meal tray to his/her roommate and failed to perform hand hygiene prior to exiting the room.-At 12:25 PM, Staff C, entered Resident ID #91's room without wearing any PPE and administered the resident's medication.-At 12:26 PM, Staff B, entered Resident ID #91's room without wearing any PPE, to deliver a meal tray to the resident. At this time, both Staff B and Staff C exited the room and failed to perform hand hygiene.-At 12:27 PM, Staff B, entered Resident ID #91's room without wearing any PPE, exited the room without performing hand hygiene, went to the clean linen cart, grabbed a towel, and re-entered the resident's room, without wearing any PPE. Further, she immediately exited the room and failed to perform hand hygiene.During a surveyor interview on 6/23/2026 at 12:28 PM, with Staff B, and NA, Staff F, they revealed that Resident ID #91 was on precautions because s/he had a history of C. Diff but indicated that s/he does not currently have C. Diff. They revealed before entering a resident's room under transmission-based precautions, they read the posted isolation signage to determine the required PPE. When the surveyor asked what PPE was required for Resident ID #91 and when it should be worn, both staff incorrectly stated that PPE was only required when providing direct care to the resident, demonstrating their understanding of EBP rather than the CP that are required. During a surveyor interview on 6/24/2026 at 3:27 PM, with the Infection Preventionist, she revealed that Resident ID #91 was suspected of having C-Diff and was supposed to be tested for it, so s/he was placed on contact precautions until the results were obtained, however, she revealed the GI panel that had been ordered did not test for C-Diff. She revealed that she would expect staff to wear PPE before entering the resident's room and to remove PPE and perform hand hygiene prior to exiting the room.Review of an Infection Prevention and Control warning for Resident ID #91 revealed that as of 6/24/2026, the resident was on contact precautions with a PPE requirement that includes gloves and gowns, due to the pending stool sample to rule out C-Diff.During a surveyor observation on 6/25/2026 at approximately 12:19 PM, the following was observed:-At 12:22 PM NA, Staff D, entered Resident ID #91's room to deliver a meal tray to the resident's roommate and failed to wear any PPE. Further, she failed to perform hand hygiene prior to exiting the room.-At 12:28 PM NA, Staff E, entered Resident ID #91's room to deliver a meal tray to the resident and failed to wear any PPE. Further, she failed to perform hand hygiene prior to exiting the room.-At 12:29 PM, Staff D, entered Resident ID # 91's room without wearing PPE and began speaking with the resident. At this time, Staff D, put on a pair of gloves while inside the room and Staff E entered the room, put on a pair of gloves while in the room, and both Staff D and E boosted the resident in bed without wearing gowns.During a surveyor interview on 6/25/2026 at 12:32 PM, with Staff D and E, they revealed Resident ID #91 was on EBP and indicated they only have to wear a gown with care, stating that they did not know they had to wear PPE since they were only in the room to deliver a meal tray, although they did perform care by boosting the resident in bed. Further, they acknowledged the CP signage posted at the resident's door and acknowledged they did not wear the appropriate PPE and failed to perform hand hygiene.Immediately following the above interview, Staff E turned away from the surveyor and walked directly into Resident ID #91's room without wearing any PPE.During a surveyor interview on 6/25/2026 at 12:44 PM, with RN, Staff L, she acknowledged that Resident ID #91 was on CP due to a pending C-Diff culture and revealed that she would expect staff to follow the signage and wear the appropriate PPE, while the resident's C-Diff culture is pending. During a surveyor interview on 6/25/2026 at 1:09 PM, with the Director of Nursing Services (DNS) she revealed that the resident is on CP while the C-Diff culture is pending and revealed that staff should follow the signage by wearing the appropriate PPE and performing hand hygiene.2. Record review revealed Resident ID #55 was admitted to the facility in June of 2026 with a diagnosis including, but not limited to, type II diabetes mellitus.Record review revealed the resident is on EBP due to a wound.During surveyor observations from 6/23/2026 through 6/26/2026, EBP signage and a bin containing PPE was noted outside Resident ID #55's room.During a surveyor observation on 6/26/2026 at 10:36 AM, Resident ID #55 was in his/her room and was being transferred by Physical Therapy Assistant, Staff M, from his/her bed to a wheelchair, where Staff M was observed to not be wearing any PPE.During a surveyor interview immediately following the above observation, Staff M acknowledged that he was not wearing any PPE, including gloves and a gown, when transferring the resident and revealed that he does not wear PPE during transfers, as it is only required for providing care.During a surveyor interview on 6/26/2026 at approximately 10:45 AM, with the DNS, she revealed that she would expect staff to wear the appropriate PPE when transferring a resident who is on EBP. Cross reference F 726

Based on record review and staff interview the facility failed to notify each resident, or resident representative, that receives Medicaid benefits when the amount in the resident's account reaches $200 less than the Social Security Income (SSI) resource limit for 5 of 6 residents reviewed with over $3800 in personal needs funds handled by the facility, Resident ID #s 17, 22, 53, 59, and 104. Additionally, the facility failed, upon a resident's death, to convey within 30 days the resident's funds and a final accounting of those funds to the individual or probate jurisdiction administering the resident's estate, in accordance with state law for 3 of 3 residents reviewed for personal needs funds handled by the facility, Resident ID #s 127, 128, and 129.Findings are as follows:1. Record review of Title 210-Executive Office of Health and Human Services, Chapter 50-Medicaid Long-Term Services and Supports (LTSS) under section 2.4 (G) of the Uniform Accountability Procedures for Title XIX Resident Personal Needs Funds in Community Nursing Facilities . requires that the facility shall: .(10) The nursing facility must notify the resident in writing when his/her balance reaches $200.00 less than the resource eligibility guideline, that Medicaid eligibility is jeopardized if the account exceeds the guideline [$4,000] .Review of a facility document titled, Trial Balance .Balances as of [DATE] for the following residents revealed:Resident ID #17 has a current balance of $4,686.66Resident ID #22 has a current balance of $3,905.68Resident ID #53 has a current balance of $4,259.15Resident ID #59 has a current balance of $3,827.61Resident ID #104 has a current balance of $8818.50Record review failed to reveal evidence that Resident ID #s 17, 22, 53, 59, and 104 were notified when their personal funds accounts were $200.00 less than the social security limit.2. Rhode Island State Regulation under section 2.4 (H) of the Uniform Accountability Procedures for Title XIX Resident Personal Needs Funds in Community Nursing Facilities .' requires that the facility shall: .(c) Upon the death of a Medicaid resident, a facility shall, within 10 days, transmit a notarized statement .indicating the amount of personal needs money on hand after funeral expenses. Funeral expenses are designated to be the first paid. Copies of receipts obtained either from the funeral home or the relative responsible for the funeral should be included .(e) If there is a balance in the Medicaid resident's personal needs account, after payment of the above noted disbursements, a check payable to EOHHS in that amount shall be sent along with the copy of the notarized statement .Record review failed to reveal evidence that the funds held by the facility were conveyed within the timeframe as required upon death for the following residents:Resident ID #127 expired on [DATE] with a remaining balance of $1021.49 in his/her personal needs account. Additional review revealed his/her funds were not conveyed until [DATE].Resident ID #128 expired on [DATE] with a remaining balance of $706.27 in his/her personal needs account. Additional review revealed his/her funds were not conveyed until [DATE].Resident ID #129 expired on [DATE] with a remaining balance of $686.24 in his/her personal needs account. Additional review revealed his/her funds were not conveyed until [DATE].During surveyor interviews on [DATE] at 11:30 AM and [DATE] at approximately 9:30 AM with the Administrator, he was unable to provide evidence that Resident ID #s 17, 22, 53, 59, and 104 were notified when their personal funds accounts were $200.00 less than the SSI limit. Additionally, he acknowledged that Resident ID #'s 127, 128, and 129 funds were not conveyed within the required timeframe after death, as required.

Based on surveyor observation and resident and staff interviews, the facility failed to follow the menu as indicated on individual dietary slips for 4 of 6 residents observed, Resident ID #s 24, 38, 81, and 104.Findings are as follows:During surveyor interviews with multiple residents during the resident council task on 6/25/2026 at 9:37 AM, ongoing complaints regarding the resident's meal items served not matching the dietary slips were alleged.Surveyor observations of the lunch meal on 6/25/2026 revealed the following:-Resident ID #24's dietary slip revealed s/he was to receive a dessert and two 8-ounce (oz) coffees; however, s/he received one 8 oz coffee and failed to receive a dessert, as indicated on his/her dietary slip.During a surveyor interview immediately following the above observation with Nursing Assistant (NA), Staff I, she acknowledged the above observation.-Resident ID #38's dietary slip revealed s/he was to receive two 4-oz whole milks; however, s/he received only one 4-oz carton of whole milk.During a surveyor interview immediately following the above observation with Staff I, she acknowledged the above observation.-Resident ID #81's dietary slip revealed s/he was to receive a garden salad; however, s/he failed to receive a garden salad.During a surveyor interview immediately following the above observation with Registered Nurse (RN), Staff J, she acknowledged the above observation.-Resident ID #104's dietary slip revealed s/he was to receive 8 oz of whole milk; however, s/he received only one 4-oz carton of whole milk.During a surveyor interview immediately following the above observation with Registered Nurse, Staff K, she acknowledged the above observation.During a surveyor interview on 6/25/2026 at 12:12 PM with the Food Service Director, he revealed that he would expect the residents to receive the food items listed on their dietary slips.

Based on clinical record review and staff interview, the facility failed to ensure that residents are free from any significant medication errors for 3 of 3 residents reviewed with blood pressure parameters, Resident ID #s 7, 65, and 108, and for 1 of 1 resident reviewed with blood sugar parameters related to insulin administration, Resident ID #11.Findings are as follows:Record review of a facility policy titled, Medication Administration dated 1/2026, states in part, .medications are administered in accordance with written orders of the prescriber.obtain and record any vital signs as necessary prior to medication administration.1) Record review revealed that Resident ID #7 was admitted to the facility in March of 2026 with a diagnosis including, but not limited to, adrenocortical insufficiency (a condition in which the adrenal glands fail to produce adequate amounts of essential hormones).Record review revealed a physician's order dated 6/1/2026 for Midodrine (a medication prescribed to treat orthostatic hypotension a drop in blood pressure when standing up) 10 milligrams (mg) three times daily. The order had instructions to hold for systolic blood pressure (SBP- the top number of a blood pressure reading) greater than 100.Record review of the June 2026 Medication Administration Record (MAR) and the vitals summary revealed that the medication was administered outside of parameters on the following dates and times:-6/1/2026 at 3:52 PM with a SBP of 111-6/5/2026 at 12:00 PM with no documented BP -6/5/2026 at 2:38 PM with a SBP of 102-6/5/2026 at 4:30 PM with a SBP of 101-6/6/2026 at 4:20 PM with a SBP of 103-6/8/2026 at 4:41 PM with a SBP of 110-6/11/2026 at 9:39 AM with a SBP of 107-6/12/2026 at 12:00 PM with no documented BP-6/13/2026 at 4:00 PM with no documented BP-6/16/2026 at 8:00 AM with a SBP of 108-6/22/2026 at 4:00 PM with a SBP of 104During a surveyor interview on 6/26/2026 at 8:46 AM with the Director of Nursing Services (DNS), she revealed that she would expect the blood pressure to be obtained, and the Midodrine to be administered according to the ordered parameters.2) Record review revealed that Resident ID #65 was admitted to the facility in January of 2026 with a diagnosis including, but not limited to, atherosclerotic heart disease (a disease caused by the build up of plaque leading to the hardening of the arteries in the heart).Record review revealed a physician's order dated 1/13/2026 for Carvedilol (a medication prescribed to treat high blood pressure) 3.125 mg two times daily. The order had instructions to hold for SBP of 100 or less or for a heart rate (HR) of 65 or less.Record review of the May and June 2026 MARs revealed that the medication was administered outside of parameters on the following dates:-5/3/2026 at 8:00 AM with a HR of 62-5/7/2026 at 8:00 AM with a HR of 63-5/11/2026 at 8:00 AM with a HR of 61-5/17/2026 at 8:00 AM with a HR of 60-5/21/2026 at 8:00 AM with a HR of 61-6/11/2026 at 8:00 AM with a HR of 63-6/13/2026 at 8:00 AM with a HR of 63-6/16/2026 at 8:00 AM with a SBP of 99-6/22/2026 at 8:00 AM with a HR of 633) Record review revealed that Resident ID #108 was admitted to the facility in December of 2025 with a diagnosis including, but not limited to, hypertension (high blood pressure).Record review revealed a physician's order dated 1/13/2026 for Metoprolol Succinate ER (a medication prescribed to treat high blood pressure) 50 mg daily. The order had instructions to hold the medication for a SBP of 110 or less or a heart rate of 65 or less.Record review of the May and June 2026 MARs revealed that the medication was administered outside of parameters on the following dates:-5/1/2026 with a HR of 62-5/3/2026 with a HR of 64-5/16/2026 with a HR of 54-5/17/2026 with a HR of 60-5/22/2026 with a HR of 63-5/25/2026 with a HR of 60-5/27/2026 with a HR of 63-5/31/2026 with a HR of 64-6/1/2026 with a HR of 60-6/4/2026 with a HR of 60-6/5/2026 with a HR of 64-6/8/2026 with a HR of 64-6/9/2026 with a HR of 62-6/15/2026 with a HR of 63-6/18/2026 with a HR of 62-6/19/2026 with a HR of 62During a surveyor interview on 6/25/2026 at approximately 10:10 AM with Registered Nurse, Staff G, she acknowledged that the above Carvedilol and Metoprolol Succinate were given outside of the ordered parameters on the above dates. 4) Record review revealed that Resident ID #11 was admitted to the facility in July of 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus.Record review revealed a physician's order dated 4/11/2026 for Novolog (Insulin) 7 units three times daily. The order had instructions to hold the medication for a blood sugar (BS) of less than 100.Record review of the June 2026 MAR revealed that the medication was held outside of the ordered parameters on the following dates and times:-6/1/2026 at 8:00 AM with a BS of 104-6/9/2026 at 8:00 AM with a BS of 101-6/17/2026 at 11:30 AM with a BS of 105-6/21/2026 at 8:00 AM with a BS of 108During a surveyor interview on 6/26/2026 at 8:32 AM with Registered Nurse, Staff H, she acknowledged the above insulin doses were held outside of the ordered parameters on the above dates. During a surveyor interview on 6/25/2026 at approximately 1:15 PM with the DNS, she revealed that she would expect the above medications to be administered as ordered by the physician based on the ordered parameters.

Based on clinical record review and staff interview, the facility failed to ensure that a resident's drug regimen is free from unnecessary drugs for 2 of 3 residents reviewed related to pharmacy recommendations, Resident ID #s 11 and 13.Findings are as follows:1) Record review revealed that Resident ID #11 was admitted to the facility in July of 2024 with a diagnosis including, but not limited to, chronic kidney disease.Record review revealed the following physician's orders:1/3/2026- alendronate sodium (a medication prescribed to increase bone mass) 70 milligram (mg) administer every Saturday 30 minutes before food, beverage, or medication.Review of a document titled, MD (Medical Doctor) Recommendations dated 4/23/2026 revealed the pharmacy recommendation to consider discontinuing his/her alendronate due to the manufacturer's recommendations related to the resident's creatinine clearance (a laboratory measure of kidney function). Further review of the document failed to reveal a response to the recommendation or a physician's signature.During a surveyor interview with the Nurse Practitioner on 6/26/2026 at 11:10 AM, she revealed that if she had been notified of the pharmacy recommendation dated 4/23/2026 she would have discontinued the alendronate.Record review of the April, May, and June 2026 Medication Administration Records (MARs) revealed that after the pharmacy made the recommendation to discontinue the alendronate on 4/23/2026, the medication continued to be administered on the following dates:-4/25/2026-5/2/2026-5/9/2026-5/16/2026-5/23/2026-5/30/2026-6/6/2026-6/13/2026-6/20/20262) Record review revealed that Resident ID #13 was admitted to the facility in February of 2025 with a diagnosis including, but not limited to, anxiety disorder.Record review revealed the following physician's orders:1/1/2026- Famotidine 10 mg (a medication prescribed to treat stomach acid) once daily.12/31/2025-Omeprazole 20 mg (a medication used to treat stomach acid) twice daily.Review of a document titled, MD Recommendations dated 4/23/2026 revealed the pharmacy recommendation to consider reducing Omeprazole to once a day, and changing famotidine to as needed.Review of a document titled, MD Recommendations dated 5/25/2026 revealed the same pharmacy recommendation to consider reducing Omeprazole to once daily and changing famotidine to as needed.During a surveyor interview on 6/25/2026 at 2:36 PM with the Nurse Practitioner, she revealed that she had verbally approved the pharmacy recommendations to decrease Omeprazole to once daily and famotidine to as needed. She further stated she would have expected the orders to have been updated.Record review of the MARs from 5/1/2026 through 6/25/2026 revealed that the resident continued to receive Omeprazole twice daily and Famotidine daily.During surveyor interviews on 6/25/2026 at 2:12 PM and 6/26/2026 at 11:10 AM with the Director of Nursing Services, she could not provide evidence that the above residents were free from unnecessary drugs.Cross reference 756

Based on clinical record review and staff interview, the facility failed to ensure that monthly pharmacy recommendations were acted upon for 2 of 3 residents reviewed, Resident ID #s 10 and 11.Findings are as follows:Review of a facility policy titled, Medication Regimen Review and Reporting [MRR] dated 1/2024 states in part, .The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen.The findings are communicated to the director of nursing or designee and the medical director.Resident-specific MRR recommendations and findings are documented and acted upon by the nursing care center and/or physician.The nursing care center follows up on the recommendations to verify that appropriate action has been taken.For those issues that require physician intervention, the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his or her rationale of why the recommendation is rejected in the resident's medical record.1) Record review revealed that Resident ID #10 was readmitted to the facility in November of 2024 with diagnoses including, but not limited to, anxiety disorder and adjustment disorder (a medical condition characterized by an excessive emotional or behavioral response to a stressful event or life change) with disturbance of conduct. Record review revealed the following physician's orders dated 4/30/2026:-Haloperidol Lactate (a medication prescribed to treat acute agitation, psychosis, and severe behavioral disturbance) 2 milligrams (mg) /milliliter (ml) administer 0.5 mg every 1 hour as needed.- Haloperidol Lactate 2 mg/ml administer 0.5 mg in the morning.-Haloperidol Lactate 2 mg/ml administer 0.5 mg at bedtime.Review of a document titled, MD [Medical Doctor] Recommendations dated 5/29/2026 revealed the pharmacy recommendation to evaluate his/her current diagnosis, behaviors and usage patterns to evaluate the continued need of the resident's orders for Haloperidol. Further review of the document failed to reveal a response to the recommendation or a physician's signature.Review of the resident's record failed to reveal evidence that the recommendation was addressed or acted upon by the facility or the resident's physician.2) Record review revealed that Resident ID #11 was admitted to the facility in July of 2024 with a diagnosis including, but not limited to, chronic kidney disease.Record review revealed the following physician's orders:-1/3/2026- alendronate sodium (a medication prescribed to increase bone mass) 70 mg administer every Saturday 30 minutes before food, beverage, or medication.-5/22/2026-Albuterol-Budesonide inhaler (a medication prescribed to relieve and prevent asthma symptoms) 90-80 micrograms (mcg)/actuation (ACT) 1 puff every 4 hours as needed for shortness of breath.Review of a document titled, MD Recommendations dated 4/23/2026 revealed the pharmacy recommendation to consider discontinuing his/her alendronate due to the manufacturer's recommendations related to the resident's creatinine clearance (a laboratory measure of kidney function). Further review of the document failed to reveal a response to the recommendation or a physician's signature.Review of a document titled, MD Recommendations dated 5/25/2026 revealed the pharmacy recommendation to consider discontinuing his/her albuterol/budesonide inhaler as the resident does not have a listed diagnosis of asthma. It recommends adding an albuterol inhaler (a medication prescribed to treat breathing difficulties caused by asthma, or exercise induced bronchospasm) instead if clinically appropriate. Further review of the document failed to reveal a response to the recommendation or a physician's signature.Review of the resident's record failed to reveal evidence that the recommendations were addressed or acted upon by the facility or the resident's physician.During a surveyor interview on 6/26/2026 at approximately 10:40 AM with the Director of Nursing Services, she acknowledged that the above pharmacy recommendations had not been addressed by the residents' physicians.Cross reference F 757

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that staff were competent to provide nursing and related services to assure resident safety to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as the facility staff were unable to differentiate between contact precautions (CP; an infection control measure used in healthcare settings to prevent the spread of germs that can be transmitted by direct or indirect contact with a resident or their environment) and 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), despite having received competency evaluations in infection control.Findings are as follows:Review of a facility policy titled Contact Precaution, last revised 10/24/2022, states in part, In addition to Standard Precautions, Contact Precautions will be used for diseases transmitted by direct of indirect contact with the resident/patient.or the patient's environment.PROCESS.Place Contact Precautions sign on door.Instruct staff, patient and their representative, and visitors regarding Precautions and the use of personal protective equipment (PPE).Staff must use barrier precautions before or upon entering the room. PPE must be worn before contact with patient or the patient's environment.Perform proper hand hygiene.as indicated by Precaution sign.Wear gown and gloves.Before exiting the room, remove and bag gown and gloves and wash hands upon exiting room.Review of an annual education/competency document titled, Infection Control and Prevention Basics, Clinical revealed the following:- Direct contact transmission occurs when microorganisms are transferred from one infected person to another person without contaminated intermediate object or person.- Indirect contact transmission involves the transfer of an infectious agent through a contaminated intermediate object or person. In the absence of a point-source outbreak, it is difficult to determine how indirect transmission occurs. However, extensive evidence suggests that the contaminated hands of healthcare personnel are important contributors to indirect contact transmission. Some examples of sources of indirect infection include the following: Hands of healthcare personnel may transmit pathogens after touching an infected or colonized body site on one patient or a contaminated inanimate object, if hand hygiene is not performed before touching another patient.- There are four key points to remember about PPE use: [NAME] the proper PPE before having contact with the patient and generally before entering the room, once PPE is on, use it carefully to prevent spreading contamination, when tasks are completed remove the PPE carefully and discard them in the receptacles provided, and immediately perform hand hygiene before going on to the next patient.Record review revealed Resident ID #91 was admitted to the facility in May of 2026 with a diagnosis including, but not limited to, Parkinson's disease.During a surveyor observation during the initial tour of the facility on 6/23/2026 at 9:42 AM, Resident ID #91's room revealed a bin of PPE and signage posted at his/her doorway which states in part, STANDARD plus CONTACT PRECAUTIONS TO PREVENT THE SPREAD OF INFECTION. Please see the Nurse before entering the patient's room. Further review of the signage states in part, Perform Hand Hygiene BEFORE and AFTER patient contact, contact with environment, [and] after removal of PPE between each resident contact. Wear Gloves upon entering this room; remove prior to exiting and discard. Wear Gown upon entering this room; remove prior to exiting and discard.Record review revealed that the following staff members completed the annual education/competency for Infection Control and Prevention Basics, Clinical, but they failed to implement proper infection prevention techniques for contact precautions based on the following observations:-6/23/2026 at 12:22 PM, Nursing Assistant (NA), Staff B, entered Resident ID #91's room without wearing any PPE or performing hand hygiene. She dropped off a meal tray to his/her roommate and failed to perform hand hygiene prior to exiting the room.-6/23/2026 at 12:25 PM, Registered Nurse, Staff C, entered Resident ID #91's room without wearing any PPE or performing hand hygiene and administered the resident's medication.-6/23/2026 at 12:26 PM, Staff B, entered Resident ID #91's room without wearing any PPE or performing hand hygiene, to deliver a meal tray to the resident. At this time, both Staff B and Staff C exited the room and failed to perform hand hygiene prior to exiting the room.-6/23/2026 at 12:27 PM, Staff B, entered Resident ID #91's room without wearing any PPE or performing hand hygiene, exited the room without performing hand hygiene, went to the clean linen cart, grabbed a towel, and re-entered the resident's room, without wearing any PPE. Further, she immediately exited the room and failed to perform hand hygiene.-6/25/2026 at 12:22 PM, NA, Staff D, entered Resident ID #91's room to deliver a meal tray to the resident's roommate and failed to wear any PPE or perform hand hygiene. Further, she failed to perform hand hygiene prior to exiting the room.-6/25/2026 at 12:28 PM, NA, Staff E, entered Resident ID #91's room to deliver a meal tray to the resident and failed to wear any PPE or perform hand hygiene. Further, she failed to perform hand hygiene prior to exiting the room.-6/25/2026 at 12:29 PM, Staff D entered Resident ID #91's room without wearing PPE or performing hand hygiene and began speaking with the resident. At this time, Staff D put on a pair of gloves while inside the room and Staff E entered the room, without PPE or performing hand hygiene, put on a pair of gloves while in the room, and both Staff D and Staff E boosted the resident in bed without wearing a gown.During a surveyor interview on 6/23/2026 at 9:45 AM, with Staff C, when asked about the signage posted outside Resident ID #91's room, she stated that the resident is no longer infected and is only on EBP, although the signage indicated the resident was on standard and CP.During a surveyor interview on 6/23/2026 at 12:28 PM, NA Staff B and NA, Staff F, stated before entering a resident's room under transmission-based precautions, they read the posted isolation signage to determine the required PPE. When the surveyor asked what PPE was required for Resident ID #91 and when it should be worn, both staff incorrectly stated that PPE was only required when providing direct care to the resident, demonstrating their understanding of EBP rather than the CP that were required. During a surveyor interview on 6/24/2026 at 3:27 PM, with the Infection Preventionist, she revealed Resident ID #91 was suspected of having C-Diff and was supposed to be tested for it, so s/he was put on contact precautions until the results were obtained. She revealed that she would expect staff to wear PPE before entering the resident's room and to remove PPE and perform hand hygiene prior to exiting the room.During a surveyor interview on 6/25/2026 at 12:32 PM, with Staff D and E, they revealed Resident ID #91 was on EBP and indicated they only have to wear a gown with care, stating that they did not know they had to wear PPE since they were only in the room to deliver a meal tray, although they were observed performing care by boosting the resident in bed. Further, they acknowledged the contact precaution signage posted at the resident's door and acknowledged they did not wear the appropriate PPE and failed to perform hand hygiene.Immediately following the above interview, Staff E, turned away from the surveyor and walked directly into Resident ID #91's room without wearing any PPE or performing hand hygiene.During a surveyor interview on 6/25/2026 at 1:09 PM, with the Director of Nursing Services, she revealed that the resident was placed on contact precautions while a C-Diff culture was pending and revealed that staff should follow the signage by wearing the appropriate PPE and performing hand hygiene.Cross Reference F-880

Based on record review and staff interview, the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed for weight gain with a history of ascites (an excess collection of fluid built up in your abdomen often caused by liver disease or certain cancers), Resident ID #108.Findings are as follows:Record review of a facility policy and procedure titled, WEIGHTS AND HEIGHTS states in part, A licensed nurse or designee will weigh the patient .weight will be entered into the .weights/vital signs module on that shift .the weights exception report will be reviewed by the licensed nurse with follow up as indicated .the licensed nurse will notify the physician .of significant weight changes .document notification .in the .progress note .Record review revealed Resident ID #108 was admitted to the facility in December of 2025 with diagnoses including, but not limited to, malignant neoplasm of the ovary (ovarian cancer) and hypertension (high blood pressure).Record review of a care plan dated 12/26/2025, revealed the resident is at risk for gastrointestinal symptoms or complications related to ascites with interventions including, but not limited to, monitor for changes in nutritional status such as unplanned weight gain and notify the physician. 1a. Record review revealed a physician's order dated 2/11/2026 to obtain weekly weights to monitor for ascites. Record review of the Weights and Vitals Summary revealed the following weights:4/1/2026: 117.3 pounds (lbs.)6/17/2026: 127.8 lbs. indicating a weight gain of 10.5 lbs. or 8.95%6/24/2026: 131.0 lbs. a total weight gain of 13.7 lbs. in less than three months indicating a 11.6% weight increase, a significant weight gain.Record review failed to reveal evidence that the provider was notified of the resident's weight gain of 13.7 lbs. from 4/1/2026 to 6/24/2026.1b. Record review revealed a Computed Tomography Scan (CT scan, a computerized x-ray imaging procedure, a diagnostic tool used to detect abnormalities in the body.) of the chest, abdomen and pelvis was completed on 5/22/2026.Record review failed to reveal evidence that the results were obtained and reported to the provider. During a surveyor interview on 6/25/2026 at 2:46 PM with the Nurse Practitioner, she revealed she was not made aware of the significant weight gain and would expect to be notified.During a surveyor interview on 6/25/2026 at 2:52 PM with the Director of Nursing Services she acknowledged that she reviewed the Weights exception report and was aware of the 13.7 lb. weight gain but failed to notify the provider. Additionally, she indicated it would be her expectation for the provider to be notified of the significant weight gain. Further, she was unable to provide evidence that the CT scan results were obtained and reported to the provider.During a surveyor interview on 6/25/2026 at 10:04 AM with the Medical Director, he indicated that he was not made aware of the significant weight gain for the resident. Additionally, he revealed that it would be his expectation that he would have made aware for staff to obtain further orders. Furthermore, he indicated that after the weight gain was brought to his attention by the surveyor, he will be adding an additional order to monitor the residents' abdominal girth (measuring the circumference of the abdomen to monitor for changes, which is typical practice for a resident with ascites).

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that the resident's environment remains as free of accident hazards as possible for 1 of 3 residents reviewed for falls, Resident ID #10.Findings are as follows:Review of a facility policy titled, Falls Management last reviewed 3/15/2024 states in part, .Patients will be assessed for risk of falling.Interventions to reduce risks and minimize injury will be implemented as appropriate.Patients experiencing a fall will receive appropriate care and post-fall interventions will be implemented.Implement and document patient-centered interventions according to individual risk factors in the patient's plan of care.Record review revealed the resident was readmitted to the facility in June of 2025 with diagnoses including, but not limited to, muscle weakness and general anxiety disorder.Review of his/her care plan revealed a focus area dated 5/27/2026 indicating that the resident is at risk for falls with interventions that include keeping the call light within reach while s/he is in bed, moving him/her to a room closer to the nurse's station, and to educate him/her for safe techniques for fall prevention.Record review revealed the resident experienced a fall on the following dates:-4/20/2026-4/22/2026-5/26/2026-6/6/2026Review of a progress note dated 4/20/2026 revealed the resident was seen by the provider following a fall where the resident was found on the floor next to his/her bed.Record review failed to reveal evidence that the resident's care plan was revised to include resident-centered post fall interventions, as per the policy.Review of a progress note dated 4/22/2026 revealed the resident experienced a witnessed fall and was lowered to the floor by staff. Additionally, it revealed that the resident would be moved to a room closer to the nurse's station due to his/her repeated falls.Record review revealed that the resident experienced two additional falls on 5/26/2026 and 6/6/2026 prior to the implementation of the resident's room change which did not occur until 6/10/2026.During a surveyor interview on 6/26/2026 at 9:47 AM with Registered Nurse, Staff O, she revealed that the resident is a fall risk and indicated that during his/her most recent fall, s/he was found on the floor lying next to his/her bed.During a surveyor observation of the resident, in the presence of Staff O on 6/26/2026 at 9:55 AM, revealed the resident in his/her bed with his/her call light on the floor underneath the foot of the bed, and out of the resident's reach. Additionally, his/her bed was noted to be in an elevated position.During a surveyor interview immediately following the above observation with Staff O, she acknowledged that the resident's call light was on the floor and his/her bed was in an elevated position. She revealed that his/her call light should be within reach and that his/her bed should be in the lowest position and proceeded to lower the bed at that time.During a surveyor interview with the Director of Nursing Services on 6/26/2026 at approximately 10:00 AM, she revealed that she would expect the resident's call light to be in reach and the bed in a safe, low position. Additionally, she revealed that she would expect a post fall intervention to be implemented and the resident's care plan to be updated to include interventions immediately following each fall.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to obtaining a stool culture for 1 of 1 resident who was suspected of having Clostridioides difficile (C. diff; a bacterium that can cause life-threatening diarrhea), Resident ID #91 and relative to oxygen administration for 1 of 1 residents reviewed, Resident ID #8. Additionally, the facility failed to meet professional standards of quality relative to 1 of 2 wound dressings observed, Resident ID #3.Findings are as follows:1. Record review revealed Resident ID #91 was admitted to the facility in May of 2026 with a diagnosis including, but not limited to, Parkinson's disease.Record review of a progress note dated 6/4/2026 at 10:07 AM revealed that the resident was observed with a recent onset of diarrhea, the Nurse Practitioner was made aware, and a stool sample was ordered to be collected to rule out C. Diff.Record review failed to reveal evidence that a physician's order was transcribed for a stool sample or that a stool sample was obtained on 6/4/2026, per the above-mentioned progress note.Further review of the progress notes revealed the following:-6/21/2026 at 7:01 PM, the resident had been experiencing loose stools with a slight odor and Resident ID #91's family member requested that the nurse obtain a physician's order for a stool sample to rule out C. Diff.-6/22/2026 at 3:43 PM, the resident experienced one episode of loose stools. The note further indicated that a C. Diff specimen was pending.-6/23/2026 at 9:19 AM, the resident's family member was hoping the C. diff test results would be back prior to his/her discharge.Record review failed to reveal evidence that a stool sample was obtained to rule out C. Diff after the resident's family member requested it, although the above-mentioned progress notes indicated that the resident continued with loose stools and the C. Diff culture was pending.During a surveyor interview on 6/24/2026 at 3:27 PM, with the Infection Preventionist, she revealed that the resident was suspected of having C-Diff and was supposed to be tested for it. Additionally, she was unable to provide evidence of a physician's order to obtain a stool sample for C. Diff or that a stool sample was obtained prior to the concern being brought to her attention by the surveyor.During a surveyor interview on 6/25/2026 at 12:49 PM, with the Nurse Practitioner, she indicated that it would be her expectation for an order to have been transcribed on 6/4/2026 and a stool sample to have been obtained to rule out C. Diff. Additionally, she indicated she would expect that staff would have followed up related to obtaining a physician's order for a stool sample to rule out C. Diff on 6/22/2026.Record review revealed a physician's order was entered on 6/24/2026, after this concern was identified by the surveyor, to obtain a stool sample for C. Diff testing.During a surveyor interview on 6/25/2026 at 1:09 PM with the Director of Nursing Services (DNS), she indicated that it would be her expectation that a physician's order would have been entered on 6/4/2026 and acknowledged there was not a physician's order in place to obtain a stool sample to rule out C. Diff until 6/24/2026, after the concern was brought to the facility's attention by the surveyor.2. Record review of a facility policy titled OXYGEN: CONCENTRATOR states in part, An oxygen concentrator extracts oxygen molecules from room air. It can be used for oxygen flow rates [how much oxygen is being delivered].verify order.Set liter flow per the order.Record review revealed Resident ID #8 was admitted to the facility in February of 2026 with a diagnosis including, but not limited to, chronic respiratory failure with hypoxia (a condition where the body is deprived of adequate oxygen).Record review of a care plan dated 2/23/2026 revealed a focus care area for Chronic Obstructive Pulmonary Disease (COPD; a long-term lung condition that causes airflow obstruction, making it difficult to breathe) with an intervention including, but not limited to, administer oxygen as ordered.During surveyor observations on the following dates and times Resident ID #8 was observed receiving oxygen via a concentrator:6/23/2026 at 12:01 PM6/24/2026 at 9:45 AM 6/25/2026 at 11:27 AMDuring a surveyor interview on 6/25/2026 at 11:27 AM with Registered Nurse, Staff K, she acknowledged that the resident was receiving oxygen and acknowledged that there was not a physician's order in place for the oxygen.During a surveyor interview on 6/25/2026 at 1:06 PM with the DNS, she revealed it would be her expectation that a physician's order for oxygen would have been obtained for Resident ID #8.3. Review of a facility policy titled, .Treatments last reviewed 7/1/2024 states in part, .A licensed nurse .will perform ordered treatments .PRACTICE STANDARDS .Perform treatment as ordered .Record review revealed Resident ID #3 was admitted to the facility in April of 2026 with diagnoses including, but not limited to, cerebral infarction (stroke) and hemiplegia (total or near total paralysis) and hemiparesis (partial weakness) affecting the right dominant side.Record review revealed a physician's order dated 6/9/2026 to cleanse the right elbow with wound cleanser, apply skin prep to the peri wound, apply triple antibiotic ointment and then cover with a silicone foam dressing every evening shift for a right elbow skin tear.Review of the June 2026 Treatment Administration Record revealed that the dressing was documented as completed as ordered on 6/22, 6/23, and 6/24/2026.During a surveyor observation of the resident on 6/25/2026 at 12:09 PM in the presence of Licensed Practical Nurse, Staff N, the wound dressing on the resident's right elbow was noted to be dated 6/22. Staff N acknowledged that the dressing was dated 6/22/2026 and did not know how frequently the dressing needed to be changed.During a surveyor interview with the DNS on 6/26/2026 at 12:30 PM, she indicated that she would expect the dressing change to have been completed as ordered on 6/23/20206 and 6/24/2026.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to maintain medical records for each resident in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 2 residents reviewed for wound dressings, Resident ID #3; for 1 of 1 resident reviewed with a fluid restriction, Resident ID #39; and for 1 of 1 resident reviewed with a significant weight gain, Resident ID #108.Findings are as follows:1. Record review revealed Resident ID #3 was admitted to the facility in April of 2026 with diagnoses including, but not limited to, cerebral infarction (stroke) and hemiplegia (total or near total paralysis) and hemiparesis (partial weakness) affecting the right dominant side.Record review revealed a physician's order dated 6/9/2026 to cleanse the right elbow with wound cleanser, apply skin prep to the peri wound, apply triple antibiotic ointment and then cover with a silicone foam dressing every evening shift for a right elbow skin tear.Review of the June 2026 Treatment Administration Record (TAR) revealed that the dressing was documented as completed on 6/22, 6/23, and 6/24/2026.During a surveyor observation of the resident on 6/25/2026 at 12:09 PM in the presence of Licensed Practical Nurse, Staff N, the wound dressing on his/her right elbow was noted to be dated 6/22. Staff N acknowledged that the dressing was dated 6/22/2026 and did not know how frequently the dressing needed to be changed.During a surveyor interview with the Director of Nursing Services (DNS) on 6/26/2026 at 12:15 PM, she indicated that she would expect the dressing change to have been completed as ordered and documented accurately in the TAR.2. Record review revealed Resident ID #39 was admitted to the facility in June of 2026 with diagnoses including, but not limited to, congestive heart failure (a chronic condition where the heart's muscle becomes too weak or stiff to pump blood efficiently), chronic kidney disease stage 5, and dependence on renal dialysis (a treatment that filters waste and excess fluid from the blood when the kidneys are failing).Record review revealed the following physician's orders dated 6/12/2026:Monitor daily fluid restriction, total 1200 milliliters (ml); breakfast tray 240 ml; free fluids day shift 180 ml; lunch tray 240 ml; free fluids evening shift 180 ml; dinner tray 240 ml; free fluids night shift 120 ml; every shift for fluid restriction.Monitor daily fluid restriction, total 1200 ml; breakfast tray 240 ml; free fluids day shift 180 ml; lunch tray 240 ml; free fluids evening shift 180 ml; dinner tray 240 ml; free fluids night shift 120 ml; one time a day for daily intake monitoring.Record review of the June 2026 Medication Administration Record (MAR) failed to reveal evidence that the resident's fluid totals for the day shift were documented on 6/16, 6/18, 6/21, and 6/25/2026.Additional record review of the June 2026 MAR revealed the resident's daily fluid intake was not accurately totaled, for 14 of 14 opportunities reviewed.During a surveyor interview on 6/26/2026 at 12:43 PM with Registered Nurse, Staff R, she indicated that the fluid totals should be documented in the MAR at the end of each shift. Additionally, she revealed that the resident's fluid totals for the day should be documented in the MAR during the night shift.During a surveyor interview with the DNS on 6/26/2026 at 12:57 PM, she acknowledged the inaccurate documentation and would expect the resident's fluid totals to be documented accurately at the end of each shift and at the end of each day.Record review revealed a physician's order dated 6/26/2026, after this concern was brought to the facility's attention by the surveyor, which states to Monitor Daily Fluid Restriction Total 1200 ml.one time a day for TOTAL FLUIDS FOR DAY.3. Record review revealed Resident ID #108 was admitted to the facility in December of 2026 with diagnoses including, but not limited to, malignant neoplasm of ovary (ovarian cancer) and hypertension (high blood pressure).Record review of an After Visit Summary from a gynecology and oncology provider dated 5/15/2026 revealed that the resident was scheduled to receive a Computed Tomography (CT, a medical imaging procedure that uses a combination of X-rays and computer technology to produce detailed, cross-sectional images of the inside of the body) scan of the abdomen, pelvis and thorax (trunk of body) on 5/22/2026.Further record review failed to reveal evidence that the results of the above CT scan were documented in the resident's record.During a surveyor interview with the DNS on 6/25/2026 at 2:52 PM, she revealed that she would expect that the resident's CT results would be obtained and documented in the resident's record.

Based on clinical record review and staff interview, the facility failed to inform the resident or the resident's appointed representative, in advance, of the care to be furnished by the physician or other provider, of the risks and benefits of proposed care or treatment alternatives relative to the ordering of, and administration of, psychotropic medications (a prescription drug designed to alter brain chemistry thus affecting a person's mind, emotions, and behavior) for 2 of 4 residents reviewed for unnecessary psychotropic medications, Resident ID #s 23 and 97.Findings are as follows:Review of a facility policy titled, Psychotropic Medication Use, dated 12/15/2025, states in part, .Psychotropic drugs include but are not limited to antipsychotics, anti-anxiety, antidepressants, or sedative-hypnotics that affect brain activities associated with mental processes and behavior.Facility staff should inform the resident and/or representative of the initiation, reason for use, and the risks associated with the use of psychotropic medications, per facility policy or applicable state regulations.A. Record review revealed Resident ID #23 was readmitted to the facility in May of 2023 with diagnoses including, but not limited to, schizoaffective disorder (a chronic mental health condition characterized by hallucinations or delusions and mood disorder symptoms), bipolar disorder (a mental health disorder that causes extreme, cyclical shifts in mood, energy, and activity level), schizophrenia (a severe brain disorder that impairs how an individual interprets reality), major depressive disorder, anxiety disorder, and adjustment disorder (a medical condition characterized by an excessive emotional or behavioral response to a stressful event or life change).Review of a care plan focus area initiated 6/5/2018 revealed s/he is at risk for complications related to the use of psychotropic medication therapy due his/her diagnoses of bipolar disorder, schizophrenia, and anxiety. Record review revealed the resident was prescribed and subsequently administered the following psychotropic medications:- 6/24/2026: Zyprexa, 10 milligrams (mg) with instructions to administer 10 mg by mouth at bedtime for schizophrenia and to give 10 mg with Zyprexa 2.5 mg to equal total dose of 12.5 mg-6/24/2026: Zyprexa, 2.5 mg with instructions to administer 2.5 mg by mouth at bedtime for schizophrenia and to give 2.5 mg with 10 mg Zyprexa to equal total dose of 12.5 mgRecord review failed to reveal evidence that the resident and/or representative were informed, in advance, of the addition of new psychotropic medications to the resident's medication regimen or dosage increases to pre-existing psychotropic medications prior to initiating therapy. Additionally, record review failed to reveal evidence that the resident and/or representative were informed of the risks and benefits, side effects, and/or treatment alternatives.B) Record review revealed Resident ID #97 was readmitted to the facility in March of 2026 with diagnoses including, but not limited to, post-traumatic stress disorder, bipolar disorder, and depression.Review of a care plan focus area last revised on 2/2/2026 revealed s/he is at risk for complications related to the use of psychotropic medication therapy.Record review revealed the resident was prescribed and subsequently administered the following psychotropic medications:-4/10/2026 to 4/23/2026: Olanzapine, 2.5 mg with instructions to administer 2.5 mg by mouth one time a day at bedtime for hallucinations for 2 weeks-4/11/2026 to 4/17/2026: Vraylar, 1.5 mg with instructions to administer one time a day for hallucinations for 1 week-4/18/2026 to 4/24/2026: Vraylar, 3 mg with instructions to administer one time a day for hallucinations for 1 week-4/25/2026: Vraylar, 4.5 mg with instructions to administer one time a day for hallucinations-6/9/2026: Trazodone, 50 mg with instructions to administer once daily at bedtime for insomnia/agitationRecord review failed to reveal evidence that the resident and/or representative were informed, in advance, of the addition of new psychotropic medications to the resident's medication regimen or dosage increases to pre-existing psychotropic medications prior to initiating therapy. Additionally, record review failed to reveal evidence that the resident and/or representative were informed of the risks and benefits, side effects, and/or treatment alternatives.During a surveyor interview on 6/25/2026 at 10:36 AM with Unit Manager, Registered Nurse, Staff J, she revealed that Resident ID #97 is his/her own responsible party and indicated that any questions about the resident's care will be discussed with the resident him/herself. She revealed that facility staff inform residents and/or representatives verbally if there is a new or increase in psychotropic medication and indicated a progress note will be entered following the conversation. Further, she was unable to provide evidence that consent was obtained from Resident ID #97 for the above psychotropic medication increases.During surveyor interviews on 6/25/2026 at 10:44 AM and 11:33 AM and on 6/26/2026 at 10:02 AM and 11:15 AM with the Director of Nursing Services, she revealed that she expects staff to obtain consent from the resident and/or representatives prior to the addition or increase in psychotropic medications and revealed that consent should be documented in a progress note or on a paper consent form. Further, she was unable to provide evidence that Resident ID #s 23 and 97 and/or their representatives were informed, in advance, of the addition of a new psychotropic medication to the resident's medication regimen or dosage increases to pre-existing psychotropic medications, the risks and benefits, side effects, and/or treatment alternatives, prior to initiating psychotropic medication therapy.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to store drugs and biologicals in accordance with currently accepted professional principles for 2 of 4 medication carts observed.Findings are as follows:Record review of a facility policy titled Medication Storage dated 1/2026, states in part, .Outdated, contaminated, discontinued or deteriorated medications.are immediately removed from stock.1) During a surveyor observation of the second-floor South medication cart on 6/25/2026 at approximately 8:00 AM, in the presence of Registered Nurse (RN), Staff Q revealed the following:-One bottle of Bisacodyl 5 milligram (mg) laxative tablets which expired on 4/2026.-Two Incruse Ellipta inhalers 62.5 microgram (mcg) (a medication prescribed to treat chronic obstructive pulmonary disease) opened and undated. The manufacturer's instruction states to discard 6 weeks after opening.-One Umeclidinium & Vilanterol Ellipta inhaler 62.5 mcg/25 mg (a medication prescribed to treat chronic obstructive pulmonary disease) opened on 2/8/2026. The manufacturer's instructions state to discard 6 weeks after opening.During a surveyor interview immediately following the observation, Staff Q acknowledged that the bisacodyl was expired, the Incruse Ellipta inhalers were opened and undated, and that the Umeclidinium & Vilanterol Ellipta inhaler has been open longer than 6 weeks and should have been discarded.2) During a surveyor observation of the first-floor North medication cart on 6/25/2026 at approximately 8:45 AM with RN, Staff L revealed the following:-One Fluticasone Propionate & Salmeterol inhaler 250mcg/50 mcg (a medication prescribed to treat asthma) opened and undated. Manufacturer's instructions on the box state to discard 1 month after opening.During a surveyor interview immediately following the above observation, Staff L, acknowledged that the Fluticasone Propionate & Salmeterol inhaler was opened and undated.During a surveyor interview on 6/25/2026 at 12:41 PM with the Director of Nursing Services, she indicated that the above inhalers should have been dated when opened. She further indicated that expired medications should have been disposed of per the manufacturer's instructions.

Based on clinical record review and staff interview, the facility failed to provide appropriate behavior monitoring for a resident with mental and psychosocial disorders and provide nursing and related services that assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 1 resident reviewed for behavior monitoring, Resident ID #23.Findings are as follows:Review of a facility policy titled, Psychotropic Medication (medication prescribed that alters brain chemistry to affect mood, thoughts, behavior, or perception).Use, dated 12/15/2025, states in part, .Facility staff should monitor the resident's behavior pursuant to Facility policy using a behavioral monitoring chart or behavioral assessment record for residents receiving psychotropic medication .Facility staff should monitor behavioral triggers, episodes, and symptoms. Facility staff should document the number and/or intensity of symptoms and the resident's response to staff interventions.Record review revealed the resident was readmitted to the facility in May of 2023 with diagnoses including, but not limited to, schizoaffective disorder (a chronic mental health condition characterized by hallucinations or delusions and mood disorder symptoms), bipolar disorder (a mental health disorder that causes extreme, cyclical shifts in mood, energy, and activity level), schizophrenia (a severe brain disorder that impairs how an individual interprets reality), adjustment disorder (a medical condition characterized by an excessive emotional or behavioral response to a stressful event or life change), major depressive disorder, anxiety disorder, and vascular dementia.Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status indicating that s/he is rarely/never understood and his/her cognition is severely impaired. Additionally, it revealed that s/he has verbal behavioral symptoms directed towards others (threatening, cursing, screaming at others) that occurred 4 to 6 days during a 7 day look back period. Further, s/he displayed behavioral symptoms not directed towards others (hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) that occurred daily during a 7 day look back period. Lastly, it revealed s/he experienced delusional behavior.Review of a care plan focus area initiated 6/5/2018 revealed s/he is at risk for complications related to the use of psychotropic medication therapy due to bipolar disorder, schizophrenia, and anxiety with an intervention to complete a behavior monitoring flow sheet.Review of the resident's Kardex (a reference tool utilized by direct care staff that outlines a resident's daily care needs) as of 6/26/2026 revealed to observe him/her for signs/symptoms of increased stimulation, belligerence, refusals of care, changes in facial expressions, body language, and to notify nursing as needed and adjust the staff's approach and interaction accordingly.Record review revealed the resident is prescribed the following psychotropic medications:-Clonazepam 0.75 milligrams (mg) at bedtime-Clonazepam 0.5 mg every eight hours as needed-Olanzapine 12.5 mg at bedtime-Rexulti 3 mg at bedtime-Trazodone 25 mg at bedtimeReview of a behavioral health follow up document dated 2/18/2026 authored by a psychiatric provider revealed to continue to monitor the resident's mood, behaviors, and psychosis (a collection of symptoms involving a loss of contact with reality).Record review failed to reveal evidence of ongoing behavior monitoring using a behavioral monitoring chart for the resident related to his/her psychotropic medication use as per facility policy and his/her comprehensive care plan.During a surveyor interview on 6/25/2026 at 2:50 PM with Licensed Practical Nurse, Staff N, she revealed that the resident is confused and behavioral at baseline.During a surveyor interview on 6/25/2026 at 3:19 PM with Nursing Assistant, Staff P, she revealed that the resident has a history of behavioral issues and accusatory behavior, can be physically aggressive, and resistive when care is being provided.During a surveyor interview on 6/26/2026 at 9:40 AM with Registered Nurse, Staff O, she revealed that behavior monitoring for residents is conducted and documented each shift in the progress notes and documented in the Medication Administration Record (MAR) with each psychotropic medication administration.Record review of the June 2026 MAR failed to reveal evidence that behavior monitoring was completed with each psychotropic medication administration.During a surveyor interview on 6/26/2026 at 10:02 AM with the Director of Nursing Services, she revealed that the facility does not utilize behavioral monitoring flow sheets. She further revealed that behavior monitoring should be conducted every shift and, in addition, observed and documented with each psychotropic medication administration.

Based on clinical record review and staff interviews, the facility failed to have sufficient nursing staff with the necessary competencies and skills to provide the required nursing and related services. This failure jeopardized resident safety and hindered the attainment or maintenance of the highest practicable physical, mental, and psychosocial wellbeing of each resident. This was particularly evident in the case of four nursing staff members: Staff B, C, D, and F, where a change in a resident's condition was not properly identified.Findings are as follows:Record review of a community reported complaint submitted to The Rhode Island Department of Health on [DATE] alleges that this facility provided Neglectful transport of a patient in a non-medical transport vehicle during [an] acute medical emergency.Review of the facility policy last revised [DATE] titled, Nursing Services states in part, .Centers will have sufficient nursing staff.in accordance with state and federal regulations, with appropriate competencies and skill sets to provide nursing and related services to assure patient safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each patient, as determined by the patient assessments and individual plans of care and.in accordance with the Facility Assessment.the Center must ensure that licensed nurses have the specific competencies and skill sets necessary to care for patients' needs.A staff's ability to use and integrate knowledge and skills must be assessed and evaluated by staff already determined to be competent in these skill areas.Review of the Facility assessment dated 2025 states in part, .[NAME] Center serves a diverse population of residents whose diagnoses and conditions span low, high, and very high acuity levels.All staff are educated, trained, and competencied on hire and annually.Licensed Nursing Staff.use Point of Care (POC) or PointClickCare (PCC) to complete orders, assessments, and documentation. The documentation entered by the nursing staff triggers alerts based on the information recorded, helping to identify any decline in the resident's condition. Staff Training & Competencies Skill Set.The practices and tools used to demonstrate the ability to identify resident changes in condition . Record review revealed the resident was admitted to the facility on [DATE] with a diagnosis including, but not limited to, a urinary tract infection (UTI).Review of the care plan dated [DATE] revealed the resident has a UTI with interventions including, but not limited to, screen the resident for sepsis and report a positive screen to a physician .2 or more of the following.Pulse [great than] 100.Respiratory rate [greater than] 20 or [oxygen saturation] 90% .Altered Mental Status- change in eye/speech/motor response.Report to physician any changes in .[vital signs] and/or condition (including subtle changes).During a surveyor interview on [DATE] at 12:26 PM with Registered Nurse (RN), Staff B, she stated that she was assigned to the resident during the 11:00 PM to 7:00 AM shift from [DATE] into [DATE]. She revealed that she found the resident confused and attempting to get out of bed his/her nasal cannula removed. She further stated the resident was short of breath with decreased oxygen saturation. Staff B stated she was unable to recall what the resident's oxygen saturation level dropped to, but she revealed that she increased the oxygen flow to 4 liters and the resident's oxygen saturation level improved. Additionally, Staff B revealed that she did not notify the provider because she did not think that this situation was a change in condition; she was unaware of the resident's baseline (typical or usual state of health) stating, I don't know, the resident could have had a diagnosis of hypoxia (an abnormally low oxygen saturation level) . She also stated that she informed the oncoming nurse to keep an eye on the resident prior to leaving the facility that morning. Lastly, Staff B ended the interview by denying that she had stated to the surveyor that the resident was confused upon her assessment. Record review failed to reveal evidence that Staff B documented in the clinical record or communicated to the oncoming staff that the resident was found without his/her nasal cannula on, required an increase in oxygen flow to achieve a normal oxygen saturation level, and was trying to get out of bed unassisted. Further record review revealed the following progress notes, authored by the oncoming RN, Staff C, who was informed by Staff B to keep an eye on the resident prior to leaving the facility on the morning of [DATE]: -[DATE] at 8:34 AM- Change to patient's baseline. Decrease in alertness, not able to follow simple commands or form words. [Vital Signs]: [blood pressure] 119/94, [heart rate] 126, [respiratory rate] 20, [oxygen saturation] 93% increased to 4 L. Spoke with .NP; patient to be sent to [emergency department] for evaluation. Transport arranged with EFG [a non-medical transportation company]. Patient's daughter [name redacted] notified and requested that patient be transferred to TMH [The [NAME] Hospital] .-[DATE] at 10:05 AM- .TMH called in to voice concern on non-medical transport for patient.Review of the Continuity of Care Acute Care Transfer Form dated [DATE], completed by Staff C, revealed the resident was unable to form sentences, required increased oxygen, was unable to follow simple commands, and was experiencing a mental status change.During a surveyor interview on [DATE] at approximately 10:40 AM with RN, Staff C, she revealed that on the morning of [DATE], the 3rd shift nurse, Staff B, had told her in report to keep an eye on [Resident ID #1] because his/her oxygen saturation had decreased into the 80's (a normal range from 95-100%) and the oxygen flow was increased from 1 L to 4 L. She further indicated that when she went in to assess the resident at approximately 8:00 AM, she noted the resident to have a decreased level of alertness and notified the nurse practitioner (NP). Additionally, she indicated that the resident was ordered to be sent out and the decision was made with the Unit Manager, Staff F, another RN on the unit, Staff D, and the Nurse Practitioner Staff E, to send the resident to the hospital via a non-medical transport.Record review of the hospital documentation dated [DATE] revealed the resident arrived at the hospital via non-medical transportation with altered mental status, shortness of breath and severe hypoxia (low oxygen saturation). The report further indicated that the resident was found to have hypercarbic hypoxic respiratory failure (a condition where the body has too much carbon dioxide and not enough oxygen in the blood), sepsis (a life-threatening condition caused by an infection), and influenza. Additional review revealed the resident was transitioned to comfort measures and expired at the hospital later that day. Record review failed to reveal evidence that competencies were completed related to identifying a resident's change in condition for the following nursing staff:-RN, Staff B-RN, Staff C-RN, Staff D-RN, Unit Manager, Staff FDuring a surveyor interview on [DATE] at 10:06 AM with the Medical Director, he indicated that he would expect a decrease in oxygen saturation to be identified as a change in condition and that a provider would be notified. Additionally, he indicated that he would expect emergency medical services to transport a resident who is experiencing a change of condition. During a surveyor interview on [DATE] at approximately 10:30 AM with the Director of Nursing Services, she could not provide evidence that Staff B, C, D, and F received education pertaining to identifying and addressing a resident's change in condition.The facility's failure to ensure its nursing staff are competent in identifying a resident's change in condition resulted in a delay in treatment for Resident ID #1. Additionally, the lack of competent nursing staff lead to the resident being transported non-emergently to a hospital (located approximately 20 minutes away from the facility) where s/he was diagnosed with sepsis and expired later that day. Furthermore, this failure placed the resident at risk for serious injury, serious harm, serious impairment or death. Cross reference F684 and F760

Based on clinical record review and staff interviews, the facility failed to ensure medications were administered as ordered. Additionally, the facility failed to recognize a change in condition in a timely manner for 1 of 1 resident reviewed, who was transferred to the hospital by a non-medical transport company, after being found by facility staff to have experienced a change in mental status, a decrease in oxygen saturation levels, and who subsequently expired, Resident ID #1.Findings are as follows:Record review of a community reported complaint submitted to The Rhode Island Department of Health on [DATE] alleges that this facility provided Neglectful transport of a patient in a non medical transport vehicle during [an] acute medical emergency.Review of a facility policy last revised [DATE] titled Change in Condition: Notification of states in part, .A Center must immediately inform the patient, consult with the patient's physician, and notify.the patient's representative, where there is.A significant change in condition in the patients physical, metal, or psychosocial status.A need to alter treatment significantly.To provide appropriate and timely information about changes relevant to the patient's condition. Record review revealed the resident was admitted to the facility on [DATE] with a diagnosis including, but not limited to, a urinary tract infection (UTI).Review of the care plan dated [DATE] revealed the resident has a UTI with interventions including, but not limited to, screen the resident for sepsis (a life threatening condition caused by an infection) and report a positive screen to a physician .2 or more of the following.Pulse [great than] 100.Respiratory rate [greater than] 20 or [oxygen saturation] 90% .Altered Mental Status- change in eye/speech/motor response.Report to physician any changes in.[vital signs] and/or condition (including subtle changes).Review of the hospital Discharge summary dated [DATE] indicated the resident was to receive Meropenem (an antibiotic) 1 gram (g) in 50 milliliters (mL) of normal saline, intravenously every eight hours for six days. Further review revealed the resident was alert and oriented to person, place, and time, and was receiving 1 liter (L) of oxygen via a nasal cannula (a thin flexible tube that is used to administer oxygen through the nose).Record review failed to reveal evidence that three scheduled doses of the Meropenem were administered as ordered.Record review failed to reveal evidence that the provider was notified that the resident had missed three doses of the antibiotics as prescribed. Record review of the progress notes revealed the resident was receiving oxygen (O2) via nasal cannula at 1 L to maintain oxygen saturation. Record review of a progress note dated [DATE] at 10:52 PM states in part, .Resident is alert and oriented x 3 . O2 91% .oxygen via nasal canula. [pulse] 96 .During a surveyor interview on [DATE] at 12:26 PM with Registered Nurse (RN), Staff B, she stated that she was assigned to the resident during the 11:00 PM to 7:00 AM shift from [DATE] into [DATE]. She revealed that she found the resident confused and attempting to get out of bed with the nasal cannula removed. She further stated the resident was short of breath with decreased oxygen saturation. Staff B stated she was unable to recall what the resident's oxygen saturation level dropped to, but she revealed that she increased the oxygen flow to 4 liters and the resident's oxygen saturation level improved. Additionally, Staff B revealed that she did not notify the provider because she did not think that this situation was a change in condition; she was unaware of the resident's baseline (typical or usual state of health) stating, I don't know, the resident could have had a diagnosis of hypoxia (an abnormally low oxygen saturation level) . She also stated that she informed the oncoming nurse to keep an eye on the resident prior to leaving the facility that morning. Lastly, Staff B ended the interview by denying that she had stated to the surveyor that the resident was confused upon her assessment. Record review failed to reveal evidence that Staff B documented in the clinical record or communicated to the oncoming staff that the resident was found without his/her nasal cannula on, required an increase in oxygen flow to achieve a normal oxygen saturation level, and was trying to get out of bed unassisted. Further record review revealed the following progress notes, authored by the oncoming RN, Staff C, who was informed by Staff B to keep an eye on the resident prior to leaving the facility on the morning of [DATE]: - [DATE] at 8:34 AM- Change to patient's baseline. Decrease in alertness, not able to follow simple commands or form words. [Vital Signs]: [blood pressure] 119/94, [heart rate] 126, [respiratory rate] 20, [oxygen saturation] 93% increased to 4 L. Spoke with .NP; patient to be sent to [emergency department] for evaluation. Transport arranged with EFG [a non-medical transportation company]. Patient's daughter [name redacted] notified and requested that patient be transferred to TMH [The [NAME] Hospital]. - [DATE] at 10:05 AM- .TMH called in to voice concern on non-medical transport for patient.Review of the Continuity of Care Acute Care Transfer Form dated [DATE], completed by Staff C, revealed the resident was unable to form sentences, required increased oxygen, was unable to follow simple commands, and was experiencing a mental status change.During a surveyor interview on [DATE] at approximately 10:40 AM with RN, Staff C, she revealed that on the morning of [DATE], the 3rd shift nurse, Staff B, had told her in report to keep an eye on [Resident ID #1] because his/her oxygen saturation had decreased into the 80's (a normal range from 95-100%) and the oxygen flow was increased from 1 L to 4 L. She further indicated that when she went in to assess the resident at approximately 8:00 AM, she noted the resident to have a decreased level of alertness and notified the nurse practitioner (NP). Additionally, she indicated that the resident was ordered to be sent out and the decision was made with the Unit Manager, Staff F, another RN on the unit, Staff D, and the Nurse Practitioner Staff E, to send the resident to the hospital via a non-medical transport.The surveyor attempted to contact Staff B, a voice mail was left; however, no return phone call was received.During a surveyor interview on [DATE] at 1:30 PM with NP, Staff E, she revealed that she was notified of the resident's change of condition, including an altered mental status and a decrease in oxygen saturation, on the morning of [DATE] and ordered the resident to be sent to the hospital for an evaluation. She further revealed that she received a verbal report of the resident's change in condition, but never assessed the resident on [DATE]. Additionally, she indicated that she would've expected the resident to be transported to the hospital for an evaluation per the facility's policy pertaining to the method of transportation that is indicated during a situation such as this.On [DATE] at 1:42 PM a policy was requested regarding transporting a resident to the hospital due to a change in condition, but was informed by the DNS that the facility did not have a policy pertaining what type of transportation is indicated when a resident is experiencing a change in condition. The DNS revealed that the mode of transportation is a clinical decision.Record review of the hospital documentation dated [DATE] revealed the resident arrived at the hospital via non-medical transportation with altered mental status, shortness of breath, and severe hypoxia. The report further indicated that the resident was found to have hypercarbic hypoxic respiratory failure (a condition where the body has too much carbon dioxide and not enough oxygen in the blood), sepsis, and influenza. Additional review revealed the resident was transitioned to comfort measures and expired at the hospital later that day. During a surveyor interview on [DATE] at 10:06 AM with the Medical Director, he indicated that he would have expected that the IV antibiotics to be administered as ordered or that a provider would be notified of the missed doses. He further indicated that he would expect a decrease in oxygen saturation to be identified as a change in condition and that a provider would be notified. Additionally, he indicated that he would expect emergency medical services to transport a resident who is experiencing a change of condition that includes, a change in metal status and a decrease in oxygen saturation. The Medical Director further revealed that he was informed that the family of this resident refused emergency medical services to transport resident because they wanted him/her to go to a particular hospital. During a surveyor interview on [DATE] at approximately 2:00 PM with the Director of Nursing Services, she indicated that the resident's family member chose non-medical transportation to ensure that the resident would be transported to a particular hospital. She further indicated that the family member had been educated that the non-medical transport could not provide any medical support during the transportation.During a surveyor interview on [DATE] at approximately 12:30 PM with the resident's family member, s/he stated that s/he did not choose the mode of transportation and was unaware that the resident was transferred to the hospital via a non-medical transport. S/he further indicated that s/he thought the transporters were emergency medical technicians (EMTs). Additionally, s/he was not informed by the facility that his/her request to transport the resident to a particular hospital meant that the resident's condition would not be monitored during the transfer to the hospital. Furthermore, s/he revealed that s/he was not made aware that the resident had missed doses of the antibiotic. The facility's failure to administer antibiotics as ordered, identify and report the resident's change in condition in a timely manner to a provider, to not transport the resident emergently to a hospital after being found by facility staff to have experienced a change in mental status and a decrease in oxygen saturation levels, where s/he was diagnosed with sepsis and expired later that day, placed the resident at risk for serious injury, serious harm, serious impairment or death. Cross reference F 695, F 726, F 760 and F 842

Based on clinical record review and staff interviews, the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed who did not receive intravenous antibiotic therapy as ordered, Resident ID #1. Findings are as follows:Record review revealed the resident was admitted to the facility on [DATE] with a diagnosis including, but not limited to, a urinary tract infection (UTI).Review of the hospital Discharge summary dated [DATE] revealed the resident was to receive Meropenem (an antibiotic) 1 gram (g) in 50 milliliters (mL) of normal saline, intravenously every eight hours for six days. Record review revealed a physician's order for Meropenem IV solution reconstituted 1 gm IV three times a day for complicated UTI, in 50 ml of normal saline until [DATE].Record review revealed Resident ID #1 missed three doses of the Meropenem IV 1 gm as ordered. During a surveyor interview with Registered Nurse (RN), Staff C on [DATE] at approximately 10:40 AM she revealed that she was unable to administer the antibiotics to the resident as it was not available. She was aware that the medication was available in the E-kit however, there were only 100 mL bags of normal saline available to reconstitute the medication so she did not give it. Additionally, she revealed that she had asked the Unit Manager, RN Staff F, how to administer the medication and was told that it couldn't be administered due to not having the correct size bag of normal saline. Lasty, Staff C revealed that the provider was notified that the resident did not receive his/her antibiotic. Further review failed to reveal evidence that the provider was notified of the missed doses of the antibiotic.During a surveyor interview on [DATE] at 9:28 AM with the Pharmacist, he acknowledged that the facility's E-kit contained Meropenem IV 1 gm, which was available for administration on [DATE]. He revealed that his expectation would have been for the facility to call the pharmacy to clarify the amount of normal saline on hand. Additionally, he indicated that he would've advised the facility to extract 50 mL of normal saline from the 100 mL bag which would have left 50 mL of normal saline for the reconstitution and the administration of the antibiotic, which would have prevented missed doses.Record review revealed the facility received a complete E-kit on [DATE].Review of the PharMerica Genesis Master E-Kit Contents List updated [DATE] revealed Meropenem IV 1 gm vial and Normal saline 100 mL, was available in the IV kit.Review of the IV E-kit utilization form failed to reveal evidence that the Meropenem or the normal saline was removed from the E-kit for administration. Review of the Electronic Shipping Manifest provided by PharMerica revealed the Meropenem and 50 ml normal saline was not delivered to the facility until [DATE] at 8:54 PM.Record review revealed the resident was sent to the hospital on the morning of [DATE] after the facility failed to administer three of five doses of the IV antibiotics as ordered.Record review of the hospital documentation dated [DATE] revealed the resident arrived at the hospital by a non-medical transportation company with altered mental status, shortness of breath, and severe hypoxia (low oxygen saturation). The report further indicated that the resident was found to have hypercarbic hypoxic respiratory failure (a condition where the body has too much carbon dioxide and not enough oxygen in the blood), sepsis (a life-threatening condition caused by an infection), and influenza. Additional review revealed that the resident was transitioned to comfort measures and expired at the hospital later that day. During a surveyor interview on [DATE] at 10:06 AM with the Medical Director, he indicated that he would expect nursing to reach out to the pharmacy for clarification and instructions. He further indicated that he would've expected the Meropenem IV 1 gm to have been removed from the E-kit and administered as ordered. During a surveyor interview on [DATE] at approximately 11:30 AM with the Director of Nursing Services, she acknowledged that the Meropenem IV 1 gm was available in the E-kit with 100 mL of normal saline. Additionally she acknowledged that the resident missed three doses of the Meropenem and could not provide evidence that a provider was notified of the missed doses. The facility's failure to administer antibiotics as ordered, resulted in the resident being transferred to the hospital where s/he was diagnosed with sepsis. Cross reference F 684, F 726 and F842

Based on clinical record review, and staff and resident interviews, the facility failed to protect and promote the rights of residents relative to preferences and privacy, for 2 of 3 residents reviewed, Resident ID #s 2 and 3.Findings are as follows:Review of the facility policy titled, Resident Rights Under Federal Law, states in part, .To treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their self-esteem and self-worth.To incorporate the resident's goals, preferences, and choices into care. 1. Record review of a facility reported incident submitted to the Rhode Island Department of Health on 1/13/2026 revealed that Resident ID #2 reported that a Nursing Assistant (NA), Staff A, was rude while providing care and not following preferences despite the resident attempting to express his/her needs. The report further revealed that the resident hit his/her head on the side rail when the NA rolled him/her to the side to provide care. Additionally, the resident was found to have a bruise above his/her left eyebrow.Record review revealed that the resident was admitted to the facility in December of 2024 with diagnoses including, but not limited to, muscle weakness and osteoarthritis.Review of the Minimum Data Set (MDS) Assessment revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderately impaired cognition. Further review revealed the resident is alert and oriented to person, place, and time. Additional review revealed the resident is dependent on staff for activities of daily living (ADLs), including rolling from side to side while in bed.Review of a care plan dated 12/19/2024 revealed the resident requires assistance with ADLs with interventions including, but not limited to, providing cueing for safety and to maximize current level of functioning, and that bed rails are used as an enabler for repositioning.Review of the SBAR [situation, background, assessment and recommendations] Communication Form completed by the Director of Nursing Services (DNS) dated 1/13/2026, revealed the resident was tearful following an alleged event involving a NA who was rude and not following the resident's preferences for care. Further review revealed the resident reported that s/he hit his/her head on the bed side rail when an NA turned the resident. A small faint bruise was found above the resident's left eyebrow. Review of the January 2026 Medication Administration Record revealed the resident received acetaminophen for head pain on 1/13/2026, following the alleged incident.During a surveyor interview on 2/11/2026 at 12:37 PM with Resident ID #2, s/he indicated that Staff A wasn't listening to how s/he is safely rolled from side to side in the bed and because of this, s/he hit his/her head on the side rail. The resident further indicated that Staff A refused to close his/her privacy curtain during care which was bothersome because his/her roommate has to walk by his/her bed to get to the bathroom.During a surveyor interview on 2/11/2026 at approximately 12:45 PM with Resident ID #2's roommate, s/he indicated that s/he was in the room during the alleged incident and heard Staff A speaking rudely to Resident ID #2. S/he further indicated that s/he heard Resident ID #2 yell ouch and was concerned about how s/he was being treated. Additionally, the s/he confirmed that the privacy curtain was open while Staff A was providing care to Resident ID #2.Staff A was called by the surveyor on 2/11/2026 at approximately 11:30 AM; a voice mail was left; however, no return phone call was received.During a surveyor interview on 2/11/2026 at 12:04 PM and at 2:02 PM with the DNS, she indicated that she assessed Resident ID #2 following the allegation of mistreatment and found a faint bruise above his/her left eyebrow, that was approximately the size of a quarter. 2. Review of a facility policy titled Pets/Animal Visits last revised 5/1/2025 states in part, .Patients must be asked if they would like to visit or interact with the animal.Review of a community reported complaint submitted to the Rhode Island Department of Health on 2/3/2026 alleges that a dog was brought into a common area of the facility, which triggered panic and anxiety for a resident. The complaint further alleges that the resident requested that the dog be removed from the common area, however the visitor initially did not remove the dog. Further, the complaint alleges that a staff member indicated that pets are allowed in the facility and that the resident should remove him/herself from the common area if s/he is uncomfortable.Record review revealed Resident ID #3 was admitted to the facility in April of 2025.Review of the MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicated intact cognition.During a surveyor interview on 2/11/2026 at 12:56 PM with Resident ID #3, s/he indicated that dogs have created extreme anxiety and panic since s/he was a child. The resident further indicated that another resident's wife brought a dog into a common area unannounced which caused him/her to panic. Additionally, the resident indicated that the Director of Social Services told him/her that s/he would have to leave the common area if s/he felt uncomfortable about the dog, and that the situation would not be discussed any further. During a surveyor interview on 2/11/2026 at approximately 1:45 PM with the Director of Social Services, she indicated that she told Resident ID #3 that s/he would have to leave the common area if s/he had a problem with a dog because residents have the right to enjoy the dogs that are brought in. She further indicated that she did not allow the conversation to continue with the resident.During a surveyor interview on 2/11/2026 at 2:06 PM with the DNS, she indicated that pets are allowed into the facility and if several residents were uncomfortable with a dog in the common area, the dog would be removed, but if one resident was uncomfortable with a dog then that resident would be removed. Additionally, she could not provide evidence that the facility protected and promoted the rights of Resident ID #s 2 and 3.

Based on record review and staff interviews, the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 1 resident reviewed who required oxygen therapy, Resident ID #1.Findings are as follows:According to Brunner and Sudarth's textbook, Medical and Surgical Nursing, 7th Edition, 1992, p. 524, as with other medications, oxygen is administered with care, and its effects on each patient are carefully assessed. Oxygen is a drug and except in emergency situations is prescribed by a physician.Record review revealed the resident was admitted to the facility on [DATE] with a diagnosis including, but not limited to, a urinary tract infection (UTI).Review of the hospital Discharge summary dated [DATE] indicated that the resident required 1 liter (L) of oxygen via nasal cannula (a thin, flexible tube that delivers oxygen through the nose).Record review of the following progress notes revealed the resident was receiving oxygen via nasal cannula:-2/5/2025 at 12:06 AM-2/5/2025 at 1:26 AM-2/6/2026 at 12:17 AM-2/6/2026 at 8:34 AMRecord review failed to reveal evidence of a physician's order for oxygen therapy.Record review failed to reveal evidence that a care plan was put into place indicating that the resident required oxygen therapy. During a surveyor interview on 2/10/2026 at approximately 10:40 AM with Registered Nurse, Staff C, she indicated that the resident was receiving oxygen via a nasal cannula since admission. She further indicated that a physician's order is usually in place if a resident requires oxygen.During a surveyor interview on 2/10/2025 at 1:42 PM with the Director of Nursing Services, she indicated that she would expect a physician's order to be in place when the resident requires continuous oxygen therapy.Cross reference F 684

Based on clinical record review and staff interview, the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed who did not receive his/her Lispro (a medication prescribed to treat elevated blood sugar levels), as ordered, Resident ID #1. The failure to administer 17 out of 17 prescribed doses resulted in elevated blood glucose levels and contributed to the resident's clinical decline, including lethargy and critically elevated blood glucose levels, requiring transfer to an acute care hospital. Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 12/9/2025, alleges in part, the resident who was discharged from the hospital returned within a week because the facility failed to accurately check the sugar levels. Additionally, the report revealed the resident was readmitted to the hospital with a glucose (blood sugar) level of 793 at arrival (normal blood glucose levels for diabetics are between 80 and 130 mg/dL (milligram/deciliter).Review of a facility policy dated 1/2023, titled Medication Administration Subcutaneous Insulin [a method of delivering insulin into the fatty tissue just below the skin with a needle] states, to administer subcutaneous insulin as ordered and in safe, accurate and effective manner. Record review revealed Resident ID #1 was admitted to the facility in November of 2025 with diagnoses including, but not limited to, end stage renal disease (kidney disease) and dysphagia (difficulty swallowing).Review of a physician's order dated 11/24/2025 revealed an order for Insulin Lispro 3 units, to be administered subcutaneously, three times daily at 9:00 AM, 1:00 PM, and 6:00 PM, beginning on 11/25/2025.Review of the November 2025 Medication Administration Record failed to reveal evidence that Resident ID #1 received Insulin Lispro, as ordered, on the following dates and times: - 11/25/2025 at 9:00 AM, 1:00 PM, and 6:00 PM - 11/26/2025 at 9:00 AM, 1:00 PM, and 6:00 PM - 11/27/2025 at 9:00 AM, 1:00 PM, and 6:00 PM - 11/28/2025 at 9:00 AM, 1:00 PM, and 6:00 PM - 11/29/2025 at 9:00 AM and 6:00 PM - 11/30/2025 at 9:00 AM, 1:00 PM, and 6:00 PMThis indicates that the resident missed a total of 17 out of 17 prescribed doses of Insulin Lispro from 11/25/2025 through 11/30/2025.Record review further revealed elevated blood glucose levels on the following dates: - 11/25/2025 - 285 - 11/26/2025 - 385 - 11/27/2025 - 250 - 11/28/2025 - 278 - 11/29/2025 - 247 - 11/30/2025 - 218 - 12/1/2025 - 582 and 483 - 12/2/2025 - 394 and 542 - 12/3/2025 - 484Record review of a progress note dated 12/3/2025 revealed, the resident was lethargic, with a low blood pressure and an elevated heart rate. The provider ordered for a complete blood count to be obtained which revealed a critically elevated blood glucose level of 658 mg/dL.During a surveyor interview on 12/9/2025 at 2:55 PM, with Licensed Practical Nurse, Staff A, she revealed she was the resident's assigned nurse during the period of 11/25/2025 through 11/30/2025. Staff A revealed that she does not remember administering the insulin lispro. Further, she indicated that the resident was transferred to an acute care hospital for lethargy and a blood sugar level over 600 on 12/3/2025. During a surveyor interview on 12/9/2025 at 3:51 PM, and 12/10/2025 at 10:16 AM, with the Director of Nursing Services, she was unable to provide evidence that the resident received the Insulin Lispro on the above-mentioned dates, as ordered.During a surveyor interview on 12/12/2025 at 12:46 PM, with the Nurse Practitioner, she indicated that she would expect the staff to follow the provider's orders.Based on the above findings, the facility failed to ensure that Resident ID #1 received Insulin Lispro, as ordered, in accordance with physician's orders and facility policy. The failure to administer 17 out of 17 prescribed doses resulted in persistently elevated blood glucose levels and contributed to the resident's clinical decline, including lethargy and critically elevated blood glucose levels, ultimately requiring transfer to an acute care hospital.

Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ensure that the residents' environment remained as free of accident hazards as possible, relative to maintaining safe water temperatures on 5 of 6 units. Findings are as follows: According to the State Operation Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, last revised 2/3/2023, states in part, .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. Many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding .The degree of injury depends on factors including the water temperature, the amount of skin exposed, and the duration of exposure . Per the State Operations Manual, for Long Term Care Facilities, (rev. 2-3-23), .Some States have regulations regarding allowable maximum water temperature . 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, F 689-Water Temps .Testing and logging Water Temperatures, states in part, .1. For burn prevention, federal guidelines advise that you keep domestic water temperatures below 120 degrees Fahrenheit, although this temp can still cause burns if exposure reaches five minutes. Many states have stricter standards that set maximum temperatures lower than 120 degrees Fahrenheit .2. Test temperature in shower areas . Record review of a facility document titled, LOGBOOK Documentation .Water Temps, revealed the most recent shower room water temperature was documented on 12/1/2023. During a surveyor observation on 3/19/2024 at approximately 1:00 PM, on the second-floor East Unit, shower room sink revealed the hot water being warm when first turned on. After a short time, the water became very hot to touch, reddening skin and steam was not rising from the sink. Following this observation, the water temperature was obtained using a digital thermometer and recorded at a temperature of 129.0 F. During surveyor observations on the following dates and times the water temperatures were found to exceed 120 degrees F: 3/19/2024- First Floor -1:08 PM: South Unit, room S25, sink 122.1 F -1:09 PM: East Unit, shower room, shower 126.1 F -1:10 PM: South Unit, room S26, sink 122.1 F -1:15 PM: South Unit, shower room, shower 126.1 F -1:20 PM: Dining room, restroom sink, 126.5 F 3/19/2024- Second Floor -1:10 PM: South Unit, shower room, shower 127.8 F -1:13 PM: Dining room, restroom sink 125.8 F -1:13 PM: East Unit, shower room, shower 127.8 F -1:15 PM: East Unit, shower room, sink 129.0 F 3/20/2024- First Floor -2:23 PM: South Unit, room S9, sink 135.1 F -2:29 PM: North Unit, room N8, sink 120.2 F -2:35 PM: East Unit, room E2, sink 129.5 F -2:37 PM: East Unit, room E5, sink 127.2 F -2:39 PM: East Unit, room E11, sink 126.7 F -2:41 PM: East Unit, room E6, sink 127.0 F -2:45 PM: East Unit, shower room, sink and tub 124.1 F 3/20/2024- Second Floor 8:07 AM: North Unit, room N2, sink 123.6 F 8:57 AM: East Unit, shower room, sink 129.0 F 9:10 AM: East Unit, shower room, shower 129.0 F 11:38 AM: East Unit, room E3, sink 125.8 F 2:30 PM: East Unit, room E1, sink 126.2 F 2:32 PM: East Unit, room E7, sink 122.6 F 2:39 PM: East Unit, room E2, sink 128.1 F 2:45 PM: North Unit, room N12, sink 123.6 F 2:48 PM: North Unit, room N8, sink 121.4 F 2:50 PM: North Unit, room N5, sink 122.6 F 2:54 PM: South Unit, room S6, sink 123.0 F During a surveyor interview and observation on 3/19/2024 at 1:04 PM, with Resident ID #15, s/he revealed that the water gets very hot and requires to be mixed with cold water. S/he stated I feel like, I could burn my hands. Further observation revealed the water temperature of the resident's sink was recorded at 122.1 F. Record review of a facility document dated 3/9/2024-3/22/2024 titled, Task: GG-Bathing for Resident ID #15, revealed s/he was documented by staff as independent for bathing and does not require staff assistance. During a surveyor interview on 3/20/2024 at 9:10 AM, with Nursing Assistant (NA) Staff L, she revealed that the water does get hot and she has to mix the water and use her hand to ensure a comfortable temperature prior to providing resident care. She further revealed that she does not use a thermometer to check the water temperature and is unaware of what the appropriate temperatures should be. During a surveyor interview on 3/20/2024 at 9:18 AM, with NA, Staff G, he acknowledged that the shower on the first-floor East Unit water temperature registered at 124.1 F. He further revealed that he would check the water temperature with his hand and let the resident feel the water prior to placing them in the shower. He indicated that he does not use a thermometer to check for water temperatures. During a surveyor observation on 3/20/2024 at 11:34 AM, of Resident ID #34, s/he was observed washing his/her face and hands using the sink in his/her room independently. During a subsequent interview following this observation s/he stated, The water does get very hot, and you need to be careful. Further observation revealed the water temperature of the sink in the resident's room was recorded at 125.8 F. Record review of a facility document dated 3/9/2024-3/22/2024 titled, Task: GG-Bathing for Resident ID #34, revealed s/he was documented by staff as independent for bathing and does not require staff assistance During a surveyor interview on 3/20/2024 at approximately 2:21 PM, with the Administrator in the presence of the Director of Nursing Services, he revealed that the water system recently had significant repairs and acknowledged the water temperatures were extremely high and should not exceed 120 F. Additionally, they were unable to provide evidence to ensure that the resident environment remained as free of accident hazards as possible. The facility's failure to maintain safe water temperatures had the potential to cause serious harm, impairment or death to the residents of the affected units. 46118 41720

Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ensure that residents with pressure ulcers receive 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 reviewed with facility acquired pressure ulcers (injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time) Resident ID #33. 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, .Stage 2 Pressure Ulcer [PU]: Partial-thickness loss .of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister . Record review revealed the resident was admitted to the facility in May of 2023 with diagnoses including, but not limited to, hemiplegia and hemiparesis (weakness and paralysis of one side of the body) and type 2 diabetes. Record review of a Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 14 out of 15, indicating the resident's cognition was intact. Further review revealed that the resident was dependent on two staff members for bed mobility, including rolling from the left to the right side while laying in bed. Record review of a care plan dated 5/22/2023 revealed the resident is dependent for Activities of Daily Living, including bed mobility, with interventions including, but not limited to, monitor for pain and complications of immobility and/or pressure ulcers. Further review revealed the resident is at risk for skin breakdown with interventions including, but not limited to, assist in turning and repositioning every 2-3 hours. Record review of a Braden Scale for Predicting Pressure Sore Risk dated 3/19/2024, revealed a score of 15, indicating the resident was at risk for developing pressure ulcers. Record review of a Skin Check dated 3/19/2024, revealed redness was noted to the resident's coccyx (tailbone/buttocks) area. Further review revealed this skin impairment was noted to be a pressure injury. Additional record review failed to reveal that any open areas were identified. During a surveyor interview on 3/21/2024 at 8:27 AM with the resident, s/he indicated that s/he asked a staff member for assistance with repositioning in bed between 5:00 AM to 6:00 AM. Additionally, the resident complained of pain to his/her buttocks however the resident was told that s/he had to wait until the next shift to be repositioned. Furthermore, the resident indicated that s/he was in pain at that time of the surveyor interview and the surveyor indicated that s/he should use his/her call light for assistance. During a surveyor observation on 3/21/2024 at 8:48 AM, two Nursing Assistants entered the resident's room to perform incontinence care and reposition the resident. At this time, the surveyor observed an open area to the resident's coccyx area. The resident expressed that s/he was much more comfortable and that his/her bottom feels much better after s/he was repositioned. During a surveyor interview on 3/21/2024 at 9:39 AM with Nursing Assistant, Staff I, who repositioned the resident in the above mentioned observation indicated that she had not repositioned the resident since the start of her shift at 7:00 AM. During a surveyor interview and observation on 3/21/2024 at 9:42 AM with the resident, the Wound Nurse, Staff J and Registered Nurse, Staff B, acknowledged that the area to the resident's coccyx was a new open area. Staff J then measured the wound and applied a protective dressing. The resident stated to Staff B that his/her pain was an 8 out of 10 to his/her coccyx area. During a surveyor interview on 3/21/2024 at 2:40 PM with Nursing Assistant, Staff K, she indicated that at approximately 6:15 AM on 3/21/2024, the resident requested to be repositioned in bed. She further indicated that she attempted to reposition the resident by herself however did not have help from another staff member at that time and told the resident s/he would have to wait to be repositioned. Additionally, she indicated that the resident complained of pain to his/her buttocks area however, she did not notify the nurse of the resident's pain. Furthermore, she indicated that she did not notice an open wound to the resident's buttocks when she provided incontinence care at that time. Record review revealed the resident was administered Tylenol 650 milligrams (mg) for coccyx pain of 8 out 10 on 3/21/2024 at 10:22 AM. Further review revealed Tylenol 650 mg was administered a second time for pain of 4 out of 10 on 3/21/2024 at 2:28 PM. Record review revealed a note dated 3/21/2024 at 11:31 AM by Staff J, indicating a new Stage 2 pressure ulcer was noted to the resident's right upper buttocks measuring 0.7 centimeters (cm) by 0.3 cm. Further review revealed a physician's recommendation to .cleanse with cleanser of choice, apply thin layer of zguard (zinc ointment) and cover with protective foam dressing daily and PRN [as needed]. Encourage OOB [out of bed] and repositioning to offload from coccyx/buttocks areas. Dietitian consulted [name redacted] and will consider adding protein supplement . During a surveyor interview on 3/21/2024 at approximately 3:00 PM with the Director of Nursing Services, she indicated that she would expect staff to request help when needed to reposition a resident who is in pain and is in need of repositioning. Additionally, she was unable to provide evidence that the resident's pain was addressed in a timely manner or that the facility ensured the necessary treatment and services, consistent with professional standards of practice, to prevent new ulcers from developing was provided.

Based on record review and staff interview if has been determined that the facility failed to promptly identify and intervene for an acute change in condition of a resident's for 1 of 1 resident reviewed for new seizure activity and physician notification, Resident ID #1. Record review of a facility reported incident submitted to the Rhode Island Department of Health on 11/17/2023 revealed in part, that Resident ID #1 experienced two seizures on 11/15/2023. Record review of a facility policy titled seizure precautions states that after full return to baseline of consciousness .notify physician/advanced practice provider (APP) and family .document: where the movement began and the body parts involve d .involuntary behavior that occurred at the onset (smacking lips, chewing movements, hand or eye movements) .patterns to activity, eye deviation, pupil changes, teeth clenching, incontinence, vomiting or salivation during the seizure .patient's response and reaction after seizure .notification of physician/APP and response .[N]otification of patient representative . Closed record review revealed that the resident was readmitted to the facility in November of 2023 with diagnoses including, but not limited to, chronic systolic heart failure (condition that occur when part of the heart cannot pump blood effectively), Hyponatremia (disorder where the level of sodium decreases in the blood), Enterocolitis (inflammation of the digestive tract due to clostridium difficile (bacteria that causes infection of the large intestine)). Record review failed to reveal evidence that the resident had a history of seizures. Record review of a nursing progress note dated 11/15/2023 at 7:50 AM reveals that the resident was working with an occupational therapist and was observed to have experienced seizure like activity that lasted 10-15 seconds. S/he was alert and oriented right after s/he experienced the seizure like activity and his/her vital signs were normal except for his/her blood pressure. The resident's blood pressure was documented as 177/72 (normal range 120/80). Record review failed to reveal evidence that the facility called the provider to alert them of the new seizure activity or increased blood pressure. Record review also fails to reveal evidence that the facility followed their own policy relative to seizures. Further record review revealed a progress note dated 11/15/2023 at 10:00 AM which indicates that Licensed Practical Nurse, Staff A was administering medications to Resident ID #1 when s/he began experiencing seizure like activity for a second time that morning. The resident became unresponsive, was not breathing and did not have a pulse. The facility initiated cardiopulmonary resuscitation and the resident was sent to the hospital via 911. Record review reveals the resident was admitted to the hospital with diagnoses of splenic infract, sepsis, acute encephalopathy and severe Clostridium difficile colitis. During a surveyor interview on 11/21/2023 at 2:03 PM with Registered Nurse, Staff B, she revealed that the resident experienced a seizure on 11/15/2023 at approximately 6:35 AM. She acknowledged that she did not call the provider about the resident experiencing new seizure activity or the increased blood pressure on 11/15/2023 at approximately 6:35 AM. During a surveyor interview on 11/21/2023 at 10:35 AM with the Physician she revealed that she was not made aware of the resident's new seizure activity noted on the morning of 11/15/2023. Additionally, she revealed that if she had been made aware of this new seizure activity for the resident who had no known history of seizures, she would have ordered the resident to be sent to the hospital for an evaluation.