Every finding on record at Sunny View Nursing Home

Based on surveyor observation, clinical record review, and staff interview, the facility failed to develop and implement comprehensive person-centered care plans for 4 of 5 residents reviewed who indicated that participation in activities of choice were important to them on their Minimum Data Set (MDS) Assessments, Resident ID #'s 5, 6, 15, and 44.Findings are as follows:Record review of an undated facility policy titled, Resident Related Care and Services states in part, .The interdisciplinary team is responsible to develop and carry out appropriate comprehensive care plans to allow for optimal outcomes.the team is to review the resident's assessment.in order to determine appropriate interventions and plans of care have been instituted. 1. Record review of Resident ID #5's Annual MDS dated [DATE] revealed s/he has a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Further review of the MDS revealed that the resident indicated participation in his/her favorite activities, keeping up with the news, going outside to get fresh air in good weather, were very important, and participation in group activities and listening to music were somewhat important to him/her.Record review of a care plan last revised on 4/9/2026 failed to reveal evidence of a comprehensive, person-centered care plan that incorporated the resident's preferences for participation in preferred activities, as identified in the MDS. 2. Record review of Resident ID #6's MDS dated [DATE] revealed s/he has a BIMS score of 12 out of 15, indicating moderate cognitive impairment. Further review of the MDS revealed the resident indicated that it is important to keep up with the news, go outside when the weather is good, and it is somewhat important to participate in group activities and listen to music.Record review of a care plan last revised on 2/9/2026 failed to reveal evidence of a comprehensive, person-centered care plan that incorporated the resident's preferences for participation in preferred activities, as identified in the MDS. 3. Record review of Resident ID #15's admission MDS dated [DATE] revealed s/he has a BIMS score of 15 out of 15, indicating intact cognition. Further review of the MDS revealed that the resident indicated that it is important to have books, newspapers and magazines to read, be around animals such as pets, do things with groups of people, do his/her favorite activities, and go outside when the weather is good.Record review of a care plan last revised on 3/10/2026 failed to reveal evidence of a comprehensive, person-centered care plan that incorporated the resident's preferences for participation in preferred activities, as identified in the MDS. 4. Record review of Resident ID #44's admission MDS dated [DATE] revealed s/he has a BIMS score of 14 out of 15 indicating intact cognition. Further review of the MDS revealed that the resident indicated that it is very important to be around animals such as pets, keep up with the news, and to go outside when the weather is good.Record review of a care plan last revised on 3/20/2026 failed to reveal evidence of a comprehensive, person-centered care plan that incorporated the resident's preferences for participation in preferred activities, as identified in the MDS.During a surveyor interview with the Director of Nursing Services on 4/29/2026 at 3:44 PM, she revealed that it is her expectation that comprehensive person-centered care plans would include the residents' activity preferences as indicated on their assessments.

Based on surveyor observation, clinical record review, and staff and resident interviews, the facility failed to provide an ongoing daily activity program to support residents in their choice of activities based on the comprehensive assessment, care plan, and preferences. Specifically for 5 of 6 residents reviewed who indicated that participation in activities of choice were important to them, Resident ID #s 5, 6, 15, 44, and 50, although this failure affects all residents residing in the facility Findings are as follows:During a surveyor interview on 4/29/2026 at approximately 11:00 AM with the members of the Resident Council, the residents revealed that activities have not been offered in the evening or on the weekends since 3/31/2026, which was the Activities Director's last day of employment at the facility.Record review revealed the facility employed only one part-time Activities Aide for the month of April 2026.1. Record review revealed Resident ID #5 was admitted to the facility in February of 2020.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Further review revealed that participation in his/her favorite activities are very important and participation in group activities are somewhat important.2. Record review revealed Resident ID #6 was admitted to the facility in February of 2026.Review of the MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15, indicating moderate cognitive impairment. Further review revealed that participation in his/her favorite activities are important and participation in group activities are somewhat important. 3. Record review revealed Resident ID #15 was admitted to the facility in March of 2026.Review of the admission MDS assessment dated [DATE] revealed a Brief Interview for BIMS score of 15 out of 15, indicating intact cognition. Further review revealed that the resident indicated that participation in his/her favorite activities and group activities are important.4. Record review revealed Resident ID #44 was admitted to the facility in November of 2025.Review of the admission MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15, indicating intact cognition. Further review revealed that the resident indicated that participation in his/her favorite activities is very important.5. Record review revealed Resident ID #50 was admitted to the facility in March of 2024.Review of the annual MDS assessment dated [DATE] revealed that the resident indicated that participation in his/her favorite activities and group activities are very important.Record review of a facility provided document titled April 2026 revealed activities are scheduled Monday through Friday at 10:30 AM, 11:00 AM, and 2:30 PM. Activities are scheduled on Saturdays and Sundays at 11:00 AM and 2:30 PM. Record review of a document titled Summary of Hours by Week dated 4/29/2026 revealed Activities Aide, Staff K, works at the facility approximately 25 hours per week. Further record review revealed there were no activities staff present in the facility to assist the residents in scheduled and individual activities on the following dates in the month of April:4/2/20264/4/20264/9/20264/11/20264/16/20264/18/20264/19/20264/21/20264/23/20264/25/2026During a surveyor interview on 4/29/2026 at 3:18 PM with the Director of Nursing Services, she acknowledged that the facility did not have an activities staff member available to the residents on the above-mentioned dates. Additionally, she could not provide evidence that the facility provides an ongoing program to support residents in their choice of activities, including facility sponsored group activities.During a surveyor interview with the Administrator on 4/29/2026 at 1:30 PM, he revealed the facility has listed the Activities Director position internally on 4/21/2026, three weeks after the prior Activities Director had left the facility.

Based on surveyor observations, record review, and staff interview, the facility failed to ensure that staff were competent to provide services to assure resident safety to attain or maintain the highest practicable wellbeing of each resident, as the facility's staff were unaware of and had not been educated on the facility's personal laundry procedures for 7 of 7 staff members reviewed, Staff A, B, C, D, E, F, and G. Findings are as follows:The facility failed to provide evidence of a policy and procedure related to residents' personal laundry to ensure staff handle, store, process, and transport all laundry in accordance with accepted national standards in order to produce hygienically clean laundry and prevent the spread of infection to the extent possible, potentially affecting all residents who reside in the facility.Review of the following staff member's completed education and competencies failed to reveal evidence that the staff were educated on the expected procedures for handling and processing of residents' personal laundry:- Nursing Assistant (NA) Staff A, with a hire date of 7/18/2026.- Dietary Aide, Staff B, with a hire date of 10/16/2025.- Housekeeper, Staff C, with a hire date of 6/4/2025.- Licensed Practical Nurse (LPN), Staff D, with a hire date of 9/5/2017.- LPN, Staff E, with a hire date of 4/23/2025.- Registered Nurse (RN), Staff F, with a hire date of 6/14/2024.- RN, Staff G, with a hire date of 4/5/2025.During surveyor observations from 4/27/2026 through 4/30/2026, laundry bins were not observed to be in resident rooms, personal laundry was observed loosely piled on the bottom of some of the residents' closets.During a surveyor observation of the laundry room on 4/29/2026 at approximately 1:45 PM, two residential washers and two residential dryers were noted. A loose pile of personal laundry was set atop one of the dryers.During a surveyor interview on 4/29/2026 at 1:45 PM with the Maintenance Director, he revealed that linens are sent out and cleaned by a contracted provider. He further revealed that the facility does not have laundry staff and the NAs are responsible to complete the residents' personal laundry. Additionally, he revealed that the washers are equipped with automatic laundry detergent dispensers. The NAs set the dryers to whatever they think is suitable.During a surveyor interview on 4/29/2026 at 1:51 PM with NA, Staff H, she indicated that the residents' personal laundry is bagged in their rooms, brought into the laundry room, and put directly into the washer. She further indicated that each resident's clothing is washed and dried individually, then brought into the resident's room to be folded or hung in the closet. Additionally, she indicated that sanitizer is not used in the washer and the dryer is on a timer.During a surveyor interview on 4/30/2026 at 9:24 AM with NA, Staff I, she stated that she was unaware of what to do with soiled undergarments or where she could rinse them if needed. Additionally, she revealed she was unaware of the facility's laundry process and procedure.During a surveyor observation of the soiled laundry room on 4/30/2026 at approximately 9:30 AM, in the presence of NA, Staff J, three bins were observed: one bin for trash, one for linens, and one for residents' personal laundry.During a surveyor interview on 4/30/2026, just prior to and during the above observation, Staff J revealed that the three bins in the soiled laundry room were for trash, linens, and residents' personal laundry respectively. He further revealed that if the resident's family does not do the personal laundry, then dirty personal laundry is brought from each of the residents' rooms and put into the bin in the soiled laundry room. Additionally, he revealed that multiple residents' personal clothing is placed into the same bin in the soiled laundry room and when the bin is full, the NA takes the bag to the laundry room and washes all of the residents' personal laundry together. Furthermore, he indicated that there is a schedule for laundry to be completed however, it is also done whenever the personal laundry bin is full.During a surveyor interview on 4/30/2026 at 9:32 AM with LPN, Staff E, she indicated that wet personal laundry should be washed immediately, however, she was unaware of where soiled laundry could be rinsed out if needed. She further indicated that the NAs follow a laundry schedule and complete the residents' personal laundry on the second and third shifts. During surveyor interviews on 4/30/2026 at 12:07 PM and at 1:15 PM with the Director of Nursing Services, she revealed that she implemented a laundry schedule and laundry was expected to be completed on second and third shifts. She indicated that the NAs are required to complete the residents' personal laundry for one resident room each night. She further indicated that residents should have a dirty laundry bin in their rooms, and that staff are educated on the facility's laundry process during orientation. Additionally, she acknowledged that the facility does not have a policy relative to the handling and processing of the residents' personal laundry. Furthermore, she could not provide evidence that laundry is reviewed during staff orientation, or that staff receive education relative to the handling and processing of personal laundry. During a surveyor interview on 4/30/2026 at 1:50 PM with the Regional Infection Preventionist (RIP), she provided the surveyor with a policy titled Laundry Guidelines, that indicated it was last reviewed 10/2018, however it was not signed by any of the facility's leadership.

Based on surveyor observation, clinical record review, and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 1 of 2 residents reviewed for the use of psychotropic medications without adequate indication of use, Resident ID #8. Findings are as follows:Record review revealed the resident was admitted to the facility in September of 2025 with a diagnosis including, but not limited to, dementia without behavioral disturbance, psychotic mood disturbance, or anxiety.Record review revealed the following physician's orders: -Lexapro (a medication prescribed to treat used to treat depression and anxiety disorder) 10 milligrams (mg) tablet once daily initiated on 3/30/2026. -Mirtazapine (a medication prescribed to treat depression) administer 7.5 mg at bedtime initiated on 4/6/2026. -Seroquel (a prescribed antipsychotic medication used to treat schizophrenia, bipolar disorder, and major depressive disorder) administer 12.5 mg at bedtime initiated on 4/22/2026. -Trazodone (a medication prescribed to treat major depressive disorder) administer 50 mg once in the morning, with a revision date of 4/22/2026. Record review of the above-mentioned physician ordered medications failed to reveal evidence of an indication for their use.During a surveyor interview on 4/30/2026 at 11:11 AM with the Nurse Practitioner, she revealed she would expect orders to contain a supporting diagnosis and indication for treatment. Additionally, she revealed that she is aware that the resident's current diagnosis of dementia without behavioral disturbances did not adequately support the use of the above-mentioned prescribed medications.During a surveyor interview on 4/30/2026 at 12:31 PM with the Director of Nursing Services, she acknowledged that the resident was receiving the above medications without adequate indications for their use.

Based on clinical record review and staff interview, the facility failed to meet professional standards of practice for 1 of 1 resident reviewed who had an order to obtain a stool sample to rule out an infectious disease, Resident ID #57.Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, .The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients .Record review revealed the resident was admitted to the facility in April of 2025 with a diagnosis including, but not limited to, functional diarrhea.Record review of the Minimum Data Set assessment dated [DATE] revealed the resident is always continent of stool.Record review revealed a physician's order for loperamide tablet (a medication prescribed for loose stool), 2 milligrams, every 8 hours as needed for loose stool.Additional record review revealed the loperamide was administered in the morning on 4/17, 4/18, 4/20 and 4/23/2026 for Diarrhea.Review of a progress note authored by the Nurse Practitioner (NP) dated 4/23/2026, states in part, .worsening loose stools with watery stool, sudden onset, occasionally incontinent.obtain C. difficile [Clostridioides difficile, a bacterial infection causing severe diarrhea and inflammation of the colon] specimen and fecal calprotectin [a stool test that measures inflammation in the intestines] for further work up.follow up for stool specimen results.Record review revealed a physician's order dated 4/24/2026 to obtain the C. diff and fecal calprotectin stool samples and to discontinue once obtained.Additional record review failed to reveal evidence that the stool samples were obtained for the above-mentioned tests as ordered.Further record review failed to reveal evidence that the NP was notified that the C. difficile and fecal calprotectin tests were not obtained until 4/28/2026, four days after it had been ordered.Record review of a progress note authored by the NP on 4/28/2026, stated in part, .Given improvement in stool frequency, there is less concern for C. difficile infection, and the C. difficile specimen can be discontinued if stool is not excessively loose or watery. However, a fecal calprotectin will still be obtained for further evaluation.more likely attributed to IBS [irritable bowel syndrome].During a surveyor interview with the Regional Infection Preventionist on 4/29/2026 at 1:07 PM, she acknowledged that the C. difficile and fecal calprotectin stool tests were not obtained as ordered.During a surveyor interview with the Director of Nursing Services on 4/30/2026 at 1:15 PM, she indicated that she would have expected the stool samples to be obtained per the physician's orders. Additionally, she would expect the provider to be notified if the samples were unable to be obtained.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to provide the necessary supervision to prevent the elopement of a cognitively impaired resident. This failure placed the resident in a situation of Immediate Jeopardy, as the resident exited the facility, undetected with another resident's visitor, and remained unsupervised in the community for approximately six hours.During this time, the resident's whereabouts were unknown, placing the resident at risk for serious harm, injury, or death. The resident was not located until s/he arrived independently at his/her former residence, where his/her spouse currently resides. The spouse then notified the facility of the resident's presence. The resident was subsequently transported to the hospital for medical clearance. Additionally, upon the resident's return to the facility, the facility failed to test the wander guard device the resident was wearing at the time of elopement and instead discarded the device without verifying its functionality, thereby eliminating the opportunity to assess whether the device functioned as intended and obscuring the facility's ability to determine the cause of the elopement. This deficient practice demonstrates the facility's failure to protect the resident from immediate risk and ensure a safe environment, resulting in a situation that was likely to cause serious harm, impairment, or death.Findings are as follows:Record review of a facility reported incident submitted to the Rhode Island Department of Health on 3/26/2026 states that Resident ID #1 was noted to be missing from the facility. Additionally, the report revealed that the resident was found at his/her previous address with his/her spouse after s/he was dropped off by another resident's visitor.Review of an undated policy titled Elopement Procedure states in part, .It is the facility policy to maintain a safe and secure environment for all residents. In order to achieve this goal, residents are to be monitored at all times. Their presence within (or absence from) the facility is to be accounted for. The charge nurse on each unit is responsible to know the whereabouts of the residents on his/her unit. Whenever a resident leaves the facility (with family or to an outside appointment), it must be noted on the sign out sheet which is kept at the receptionist desk in the lobby.Record review of an undated facility policy titled Wander guard System and Assessments; checks revised on 2/7/2025 states in part, . [the facility] will maintain a safe environment for all residents. Those residents identified as an elopement risk will wear a wander guard bracelet to assure optimal safety.Record review revealed the resident was admitted to the facility in August of 2024 with diagnoses including, but not limited to, dementia, cognitive communication deficit, and anxiety disorder.Record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 4 out of 15 on his/her Brief Interview for Mental Status (BIMS) score, indicating severe cognitive impairment.Record review of a care plan dated 9/6/2024 revealed the resident wears a wander guard bracelet (a safety mechanism intended to monitor and prevent at-risk residents from exiting unsupervised) following his/her attempts to leave the facility. Interventions include but not limited to, ensure the wander guard device is in place, assess the functioning, the battery status of the device weekly, and provide visual checks or supervision for the resident's safety. Further review revealed a revised dated 7/5/2025 which indicated the resident is at risk for altered cognition with periods of forgetfulness and confusion related to his/her diagnosis of dementia and cognitive impairment.Record review of physician orders revealed the following:7/11/2025: Check placement of the Tektone (wander guard/elopement prevention device) bracelet every shift on the left ankle.1/30/2026: Check the functionality of the Tektone device weekly on Fridays.Record review of the March 2026 Treatment Administration Record (TAR) indicated that staff documented the wander guard device as in place during first and second shifts on 3/25/2026, reflecting that the resident was wearing the bracelet. Further review of the TAR showed documentation that the device's functionality was checked and noted as operational on 3/20/2026.During a surveyor interview on 3/26/2026 at approximately 11:00 AM with Licensed Practical Nurse (LPN), Staff A, she revealed that she was the 7:00 AM to 3:00 PM shift nurse on 3/25/2026. Additionally, she revealed that she had observed the wander guard on the resident's left ankle when s/he was being accompanied to the activities room for the Bingo at approximately 2:30 PM on 3/25/2026.During a surveyor interview conducted on 3/26/2026 at 12:38 PM, LPN, Staff B, stated that she last observed the resident on 3/25/2026 at approximately 3:30 PM in the activity room. At that time, the resident was wearing a wander guard bracelet on his/her left ankle and was seated with a visitor engaged in conversation.Staff B reported that at approximately 4:30 PM, when she went to escort the resident to dinner, she was unable to locate him/her. She further stated that at approximately 5:00 PM, she contacted the resident's spouse to determine if s/he had taken the resident from the facility. The spouse informed Staff B that s/he did not have the resident and was unaware that the resident was missing.Additionally, Staff B stated that after speaking with the resident's spouse, she notified the management team that the resident could not be located. The management team subsequently initiated the facility's elopement protocol. According to Staff B, a comprehensive search was conducted, including a room-to-room sweep of the facility as well as a search of the immediate surrounding neighborhood, including gas stations, local stores, and the mall. Staff B further reported that upon returning to the facility at approximately 6:30 PM, law enforcement was on site and actively interviewing the Director of Nursing Services (DNS) Additionally, Staff B reported that law enforcement initiated a Silver Alert at approximately 8:00 PM. However, at approximately 9:00 PM, the resident's spouse contacted the facility to report that an individual had dropped the resident off at the family's home. During a surveyor interview on 3/26/2026 at approximately 2:00 PM, the resident's spouse reported being shocked when the resident arrived at the front door unaccompanied. The spouse stated that the resident appeared visibly confused, was holding a sandwich, and was unable to explain how s/he arrived home. The spouse further reported that the resident was immediately transported to the hospital for evaluation.Review of the Emergency Medical Services (EMS) run report dated 3/25/2026 revealed that per the resident's spouse, s/he arrived at the family's home with a sandwich in his/her hand without a recollection of how s/he got there. Additionally, the EMS report revealed that the resident was transferred to the hospital for an evaluation related to being missing for several hours from the facility.Review of a hospital document titled After Visit Summary, dated 3/25/2026, revealed that the resident presented following elopement from the nursing home. The resident was unable to account for his/her whereabouts during the preceding hours and could not recall whether any falls or injuries had occurred. The resident reported throat and chest pain rated at 10 out of 10, indicating severe, unbearable pain. Further review of the document indicated that the resident arrived at the hospital with an ankle monitoring device in place on the left ankle.Review of a nursing progress note revealed that the resident returned to the facility at 5:00 AM on 3/26/2026. Review of a nursing progress note authored by the Regional Nurse on 3/26/2026 at 8:00 AM revealed that the resident had no recollection of the incident and out of an abundance of caution a new wander guard device was applied to his/her left ankle.Further record review failed to demonstrate that the facility evaluated or tested the resident's prior wander guard device for functionality upon his/her return on 3/26/2026 before issuing a replacement device.During a surveyor interview on 3/26/2026 at approximately 12:00 PM, the Regional Nurse acknowledged that the resident was provided a new wander guard device upon return from the hospital that morning. When asked to produce the original device, she stated that it had been discarded without being assessed for proper functioning.During a surveyor interview on 3/27/2026 at 9:22 AM, the Activities Director reported that bingo was held on 3/25/2026 from 2:40 PM to 3:40 PM. She stated that Resident ID #1 was not actively participating in the game but appeared to be engaged in a pleasant conversation with a female companion. The Activities Director further noted that when bingo concluded, nursing staff were called to escort all residents, including Resident ID #1, back to their units. She added that she did not observe the resident or the visitor leave the facility and did not hear the wander guard alarm sound at the exit.During a surveyor interview on 3/27/2026 at 9:30 AM, the Receptionist reported that she worked from 8:00 AM to 4:00 PM on 3/25/2026. She stated that she does not remain at the front desk continuously, as she frequently moves between the desk and the resident units. The Receptionist further indicated that while walking toward the North Unit at approximately 4:00 PM, she observed the resident and a visitor walking together toward the South Unit, which leads to the facility's main entrance/exit. She noted that she did not hear the wander guard alarm sound at the exit.During a surveyor interview on 3/27/2026 at 10:29 AM, the visitor stated that she was at the facility on 3/25/2026 to visit another resident. She admitted that Resident ID #1 expressed a desire to go to his/her home, and she proceeded to remove the resident from the facility, drive him/her to the spouse's house, drop him/her off, and leave without ensuring the resident's safety or notifying staff. The visitor further disclosed that she and the resident exited the facility through the main entrance/exit door, and that the wander guard alarm did not sound during their departure. When asked whether she had been provided a door code to enter or exit the facility, she stated that she had never been given one.During a surveyor interview on 3/27/2026 at approximately 11:00 AM with the Regional Administrator, in the presence of the Regional Nurse, they reported that a family member of another resident had observed the visitor exiting the facility with Resident ID #1 on 3/25/2026 at approximately 4:00 PM through the main entrance/exit door.In a separate surveyor interview on 3/27/2026 at 10:22 AM with that family member, he stated that at approximately 4:00 PM on 3/25/2026, he was sitting on the patio near the facility entrance when he witnessed the visitor leaving the facility with the resident. He noted that the door alarm did not sound as they exited and that he did not see the visitor enter a door code prior to leaving. During a surveyor interview on 3/27/2026 at approximately 2:00 PM with both the Regional Administrator and the Regional Nurse, they were unable to provide evidence that the previous wander guard device was checked or tested for functionality upon the resident's return to the facility before it was disposed of. They acknowledged that the resident had eloped from the facility and that they were unaware of his/her whereabouts for approximately six hours. The Administrator further stated that it was unclear whether the wander guard system had failed, the alarm sounded but staff did not respond, or the visitor had entered the door code. He explained that although the resident was wearing the wander guard device, the door alarm would not activate if a visitor used the code to exit. When asked why a visitor would have the door code, the Administrator confirmed that visitors should not be given the code, as they are not facility employees.The facility failed to ensure the safety of Resident ID #1, who was identified as at risk for elopement. Despite the resident wearing a wander guard device, the resident was able to leave the facility unsupervised for approximately six hours on 3/25/2026, during which time staff were unaware of his/her whereabouts. The facility did not verify the functionality of the resident's wander guard device upon return, and the previous device was discarded without assessment.Interviews with staff and visitors confirmed that the resident exited the facility with a visitor through the main entrance/exit door, and the wander guard alarm did not activate. Additionally, the facility was unable to provide documentation confirming that staff consistently monitored the resident in accordance with facility policy and physician orders.These failures placed the resident in at risk for serious injury, serious harm, serious impairment or death.

Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident receives assistive devices to prevent accidents relative to the placement of a TekTone device (a device that allows at-risk residents to move freely about a facility, while preventing them from exiting the facility) for 1 of 1 resident who successfully eloped from the facility and sustained a major injury, Resident ID #1. Findings are as follows: Review of the facility policy titled Elopement Assessment dated 10/27/2022 states in part, .It is the facility policy to maintain a safe and secure environment for all residents. In order to achieve this goal residents who are at risk for wandering/elopement need to be identified and a care plan developed with interventions to minimize or eliminate the risk as outlined below .Residents who are at risk for elopement include those with dementia, confusion .may warrant close watching .if the resident is assessed to be at risk for elopement, then the necessary and appropriate intervention must be put in place immediately to keep the resident safe i.e , wander guard bracelet, frequent checks, etc . Review of an additional facility's policy titled Wanderguard [TekTone device] System and Assessments Checks dated 2/7/2025 states in part, .The bracelet will be checked each shift to assure placement, the nurse will sign this as checked in the treatment record . Record review of a facility reported incident sent to the Rhode Island Department on Health on 6/16/2025 revealed that Resident ID #1 was found in the rear parking lot of the facility by a staff on the overnight shift on 6/12/2025. S/he was noted to have a large hematoma above the left eye and his/her left leg was externally rotated and s/he complained of pain. S/he was tranferred to an acute care hospital where s/he was diagnosed with a left hip fracture. Record review revealed Resident ID #1 was admitted to the facility's semi-secure unit in March of 2022 and readmitted in April of 2025 with diagnoses including, but not limited to, altered mental status, cognitive communication deficit, insomnia, and muscle weakness. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 6 out of 15 on his/her Brief Interview for Mental Status (BIMS) assessment, indicating severe cognitive impairment. Record review of a care plan dated 6/9/2025 revealed the resident is at risk for wandering and elopement related to diagnoses of dementia and cognitive decline with a goal for the resident to remain on the unit at all times unless leaving with staff or family. Staff interventions include but are not limited to, Frequent visual checks .Redirect away from exits .Engage in activities if applicable . Record review of a physician's order dated 4/17/2025 revealed to check the placement of the TekTone elopement prevention bracelet every shift. Further review revealed that the frequency of this order was transcribed incorrectly. The order was transcribed to be completed once daily on Mondays, indicating that the placement would be checked one time a week and not every shift as ordered by the physician. Review of the resident's MDS Assessments Summary dated 4/18/2025 section P Restraints and Alarms failed to reveal evidence that the resident was coded as having a TekTone elopement prevention bracelet in place. Review of the June 2025 Treatment Administration Record revealed the resident's TekTone bracelet was last checked on 6/9/2025 during the 11:00 PM to 7:00 AM shift, which was three days prior to the elopement incident on 6/12/2025 night. Record review of a progress note dated 6/13/2025 at 1:36 AM authored by Registered Nurse, Staff A, revealed that the resident was found by staff in the rear parking lot at approximately 11:15 PM lying on the ground. The TekTone monitoring device was not located on the resident. The resident was alert and confused, with a large hematoma (a collection of blood outside of a blood vessel, often caused by injury) above his/her left eye, his/her left leg was noted to be externally rotated and s/he was complaining of pain. Further record review revealed the resident was transferred to an acute care hospital and was diagnosed with a left hip fracture. Review of a physician's order dated 4/23/2025 revealed that the resident is to receive the following medications at bedtime every day: - Melatonin 5 MG (milligrams) for insomnia - Trazodone 12.5 MG for insomnia - Eliquis 2.5 MG for blood clot - Tylenol 1000 MG for pain - Omeprazole 40 MG for stomach ulcer or heart burn - Latanoprost eye drops 0.005% for glaucoma - Methenamine hippurate 1 gram for urinary tract infections prevention. Review of the June 2025 Medication Administration Record failed to reveal evidence that the above-mentioned bedtime medications were signed off as administered on 6/12/2025 before his/her elopement incident. During a surveyor interview on 6/18/2025 at 1:26 PM with Staff A, he indicated that the resident's bedtime medications were not administered because s/he wasn't in his/her room at 11:15 PM at the time of the administration. When Staff A was asked as to why he waited until 11:15 PM to give the resident his/her bedtime medications, he indicated that it was a busy night and that he had not see the resident from the start of his shift (9:00 PM) until s/he was found outside of the facility. Additionally, Staff A, revealed that the resident did not have a TekTone elopement prevention device on when s/he was found on the ground outside of the facility on the night of 6/12/2025. During a surveyor interview with Nursing Assistant (NA), Staff B, on 6/18/2025 at 3:22 PM, he stated that he had last seen the resident in his/her room at approximately 10:30 PM during the rounds on the evening of 6/12/2025. Additionally, Staff B stated that he was unable to recall if the resident had a Tektone monitoring device on him/her during evening rounds. During a surveyor interview with NA, Staff C, on 6/20/2025 at 4:24 PM, he revealed that on 6/12/2025 at approximately 11:40 PM, he was routinely checking the outside of the facility when he saw something on the ground behind the kitchen. However, he thought it was a trash bag that was left out by staff. He indicated that when he got closer, he observed Resident ID #1 laying on the ground, calling for help. Further, Staff C revealed that he ran back into the building to alert the staff on Resident ID #1s unit that s/he was outside. This indicates that approximately 1 hour and 10 minutes had passed since s/he was last seen by staff in the facility. During a surveyor interview on 6/18/2025 at 12:03 PM with Director of Nursing Service, she indicated that she was unsure which door the resident exited the facility from. She indicated that the resident may have exited the building from the exit door closest to his/her room. Additionally, she revealed that all exit doors would have locked if the resident had been wearing a TekTone device. Furthermore, she acknowledged that the resident did not have a TekTone device on when s/he was found on the ground outside of the facility on 6/12/2025 at 11:15 PM. Lastly, she was unable to provide evidence that the facility's policy to check the TekTone device each shift to assure placement was followed. During a surveyor interview on 6/23/2025 at approximately 1:00 PM with the Nurse Practitioner, she revealed that two weeks prior to the elopement, it was reported to her that the resident had taken off the Tektone bracelet. Additionally, she indicated that she would have expected the staff to frequently check the TekTone elopement bracelet every shift daily for the safety of the resident. The facility's failures to follow their policy to ensure placement of the TekTone device every shift, and correctly transcribe the physician's order to verify the placement of a TekTone bracelet three times daily, resulted in a cognitively impaired resident who was identified as a wander risk, not having a TekTone device in place. Because the assistive device was not in place, s/he was able to exit the facility through unlocked doors (that would have locked if s/he had been wearing a TekTone device), placing him/her at risk for more than minimal harm, impairment, or death. Cross reference F 842.

Based on record review and staff interview, it has been determined that the facility failed to ensure that resident records are complete and accurately documented, relative to the monitoring of an elopement prevention device, a TekTone device (a device that allows at-risk residents to move freely about a facility, while preventing them from exiting the facility), for 1 of 1 resident reviewed who eloped from the facility and sustained a hip fracture, Resident ID #1. Findings are as follows: Review of a facility's policy titled Wanderguard [TekTone device] System and Assessments checks states in part .The bracelet will be checked each shift to assure placement, the nurse will sign this as checked in the treatment record . Record review of a facility reported incident submitted to the Rhode Island Department on Health on 6/16/2025 revealed that Resident ID #1 was found in the rear parking lot of the facility by a staff on the overnight shift on 6/12/2025. S/he was noted to have a large hematoma above the left eye, his/her left leg was externally rotated and s/he complained of pain. Record review revealed the resident was admitted to a semi-secured unit of the facility in March of 2022 and readmitted in April of 2025 with diagnoses including, but not limited to, altered mental status, cognitive communication deficit, muscle weakness, and insomnia. Review of the Quarterly Minimum Data Set Assessment revealed the resident scored a 6 out of 15 on his/her Brief Interview for Mental Status assessment, indicating severe cognitive impairment. Record review of a care plan dated 6/9/2025 revealed the resident is at risk for wandering and elopement related to diagnoses of dementia and cognitive decline with a goal for the resident to remain on the unit at all times unless leaving with staff or family. Staff interventions include but are not limited to, Frequent visual checks .Redirect away from exits .Engage in activities if applicable . Record review of a physician's order dated 4/17/2025 revealed to check the placement of the TekTone elopement prevention bracelet every shift. Further review revealed that the frequency of this order was transcribed incorrectly. The order was transcribed to be completed once daily on Mondays, indicating that the placement would be checked one time a week and not every shift as ordered by the physician. Record review of the June 2025 Treatment Administration Record revealed the placement of the TekTone device was last checked on 6/9/2025 on the 11:00 PM to 7:00 AM shift which was 3 days prior to the resident's elopement on 6/12/2025. Record review failed to reveal evidence that the resident's TekTone device was being checked every shift as ordered since it was last checked on 6/9/2025. Record review of a progress note dated 6/13/2025 at 1:36 AM authored by Registered Nurse, Staff A, revealed that the resident was found by staff in the rear parking lot at approximately 11:15 PM lying on the ground. The TekTone monitoring device was not located on the resident. The resident was alert and confused, with a large hematoma (a collection of blood outside of a blood vessel, often caused by injury) above his/her left eye, his/her left leg was noted to be externally rotated and s/he was complaining of pain. Further record review revealed the resident was transferred to an acute care hospital and was diagnosed with a left hip fracture. During a surveyor interview on 6/18/2025 at 1:26 PM with Registered Nurse, Staff A, he revealed that the resident didn't have the TekTone elopement prevention device on when s/he was found on the ground outside of the facility on the night of 6/12/2025. During a surveyor interview with Nursing Assistant, Staff A, on 6/18/2025 at 3:22 PM he stated that he was unable to recall if the resident had a TekTone monitoring device on him/her on the last round during the evening shift of 6/12/2025. During a surveyor interview with the Director of Nursing Services, on 6/18/2025 at approximately 3:30 PM, she revealed that the order dated 4/17/2025 was transcribed in error, and the TekTone monitoring device should have been checked for placement every shift, every day. During a surveyor interview on 6/23/2025 at approximately 1:00 PM with the Nurse Practitioner, she revealed that two weeks prior to the resident's elopement, it was reported that the resident had taken off the TekTone elopement prevention device. Additionally, she indicated that she would have expected the staff to follow the physician order which is to check the device placement daily on every shift for the safety of the resident. Due to the facility's failure to accurately transcribe and implement a physician's order regarding the monitoring the placement of the TekTone device, a cognitively impaired resident-identified as a known wander risk, exited the facility, fell and sustained a hip fracture. This failure placed the resident at risk for more than minimal harm, impairment, or death. Cross reference F689

Based on record review and staff interview, it has been determined that the facility failed to ensure that the Minimum Data Set (MDS) Assessment accurately reflected the resident's status for 1 of 2 residents reviewed who are assessed an an elopement risk, Resident ID #5. Findings are as follows: Record review revealed Resident ID #5 was readmitted to the facility's semi-secure unit in March of 2025 with diagnoses including, but not limited to, mild cognitive impairment and muscle weakness. Record review revealed that a care plan was initiated on 6/9/2025 indicating the resident requires the use of a TekTONE elopement prevention bracelet related to episodes of attempting to leave the facility with approaches/interventions including, but not limited to, ensuring that the TekTone elopement prevention bracelet is in place and its functionality, providing visual checks/supervision for safety. Review of the quarterly MDS Assessments dated 2/26/2025 and 4/3/2025 section Restraints and Alarms failed to reveal evidence that the resident was coded as having a TekTone elopement prevention bracelet in place. During a surveyor interview on 6/23/2025 at approximately 1:00 PM with the MDS Coordinator, she acknowledged that the resident wears a TekTone bracelet related to being at risk for elopement. Additionally. she revealed that they was coded inaccurately in the Section P Restraints and Alarms of the MDS. During a surveyor interview on 6/23/2025 at approximately 2:00 PM with the DNS, she was unable to provide evidence that Resident ID #5 was coded as having a TekTone elopement prevention bracelet in the section P of his/her MDS assessment.

Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality for 2 of 3 residents reviewed for physician's orders, Resident ID #s 1 and 3. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review of a community reported complaint submitted to the Rhode Island Department of Health on 5/5/2025 alleged that Resident ID #1 was complaining of abdominal pain and was observed with large purple bruising extending from his/her upper chest to the upper abdomen. 1. Record review revealed Resident ID #1 was admitted to the facility in February of 2025 with diagnoses including, but not limited to, altered menial status and a fall. Record review revealed a physician's order dated 3/6/2025 to complete a weekly skin evaluation and document the findings under observations. Record review of the April 2025 Medication Administration Record (MAR) revealed the weekly skin evaluation was signed off as completed on 4/26/2025. Record review of the Weekly Skin Evaluation Observations and progress notes failed to reveal evidence that the weekly skin assessment was completed and documented on 4/26/2025, although it was signed off as being completed on the MAR. 2. Record review revealed Resident ID #3 was admitted to the facility in April of 2025 with diagnoses including, but not limited to, Parkinson's Disease, dementia, and fracture of the nasal bones. Record review revealed a physician's order dated 4/27/2025 to complete a weekly skin evaluation and document the findings under observations. Record review of the April and May 2025 MAR revealed the weekly skin evaluations were signed off as completed on 4/28/2025 and 5/5/2025. Record review of the Weekly Skin Evaluation Observations and progress notes failed to reveal evidence that the weekly skin assessments were completed and documented on 4/28/2025 and 5/5/2025, although they were signed off as being completed on the MAR. During a surveyor interview on 5/6/2025 at 2:51 PM with the Director of Nursing Services, she was unable to provide evidence that weekly skin assessments were completed, per the physician's order.

Based on record review, resident, and staff interview, it has been determined that the facility failed to accurately maintain the resident's medical record in accordance with accepted professional standards and practices for 1 of 1 resident reviewed with updated medication orders, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 3/19/2025, alleged that Resident ID #'s 1 medical needs have not been met. Record review revealed that the resident was admitted to the facility in January of 2025 with diagnoses including, but not limited to, exocrine pancreatic insufficiency (a condition in which the pancreas does not produce enough digestive enzymes, leading to problems breaking down food), orthostatic hypotension (a condition when the blood pressure drops significantly when a person stands up from a sitting or lying position), and repeated falls. A. Record review of a progress note dated 3/24/2025 authored by Licensed Practical Nurse (LPN), Staff A, revealed in part, that the Nurse Practitioner (NP), Staff B, visited the resident and increasd his/her dose of Spironolactone (a medication prescribed to reduce fluid in the body and to lower your blood pressure) to 37.5 milligrams (mg) daily from 25 mg. Record review of the physician's orders revealed the following: -Spironolactone tablet; 25 mg, with a start date of 3/14/2025 -Spironolactone tablet; 37.5 mg; with a start date of 3/24/2025 Record review of the May 2025 Medication Administration Record (MAR) revealed that the above-mentioned medications were both administered to the resident on 3/25/2025. During a surveyor interview on 3/25/2025 at 12:56 PM with Staff A, she acknowledged that both of the above mentioned orders for Spironolactone were documented as adminstered. Additionally she denied administering the Spironolactone 25 mg to the resident. During a surveyor interview on 3/25/2025 at approximately 3:15 PM with the Administrator, she indicated that she would expect staff to discontinue the medication and to initiate a new order with the correct medication dose. Additionally, she was unable to provide evidence that the medication administration was documented accurately. B. Record review of a progress note dated 3/24/2025 authored by Licensed Practical Nurse (LPN), Staff A, revealed that the Nurse Practitioner (NP), Staff B, visited the resident and prescribed new orders including in part, tucks pads (a medication used to relive pain caused by hemorrhoids) after each bowel movement and to assess his/her blood pressures (BP) two times a day, for 7 days. Record review revealed failed to reveal evidence that a physician's order was in place for tucks pads and for the BP to be taken twice a day, as ordered. Record review of the BP reports and the progress notes failed to reveal evidence that the resident's BP was assessed after the provider initiated the order on 3/24/2025. During a surveyor interview on 3/25/2025 at approximately 10:30 AM with the resident, s/he revealed that s/he made the NP aware of the pain caused by the hemorrhoids. Additionally s/he stated that has not received any treatment for the pain caused by the hemorrhoids. During a surveyor interview on 3/25/2025 at 1:53 PM with Staff A, she acknowledged that the physician's order initiated on 3/24/2025 for the use of tucks pads after each bowel movement was not transcribed and completed, as ordered. During a surveyor interview on 3/25/2025 at 3:01 PM with Registered Nurse, Staff C she acknowledged that the physician's order initiated on 3/24/2025 for the assessment of BP twice a day for 7 days was not transcribed and completed, as ordered. During a surveyor interview on 3/25/2025 at approximately 3:15 PM with the Administrator, she was unable to provide evidence that the above mentioned orders were transcribed into the resident's record or initiated until the facility staff was made aware by the surveyor.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, relative to the main kitchen and the main dining room. Findings are as follows: 1. Review of the Rhode Island Food Code, 2018 Edition, section 3-501.17 states in part, .(B) .refrigerated, ready-to-eat time/temperature control for safety food .shall be clearly marked, at the time the original container is opened in a food establishment .and: (1) the day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date . During the initial tour of the main kitchen on 3/10/2025 at approximately 8:25 AM of the reach in refrigerator, the following was observed: -One, 8 pound (lb.) container of Cross Valley Farms Fruit Salad Deluxe in light syrup approximately 3/4 full, open and not dated. -One, 1 gallon pitcher of orange liquid approximately 1/2 full, not labeled or dated. -One, 1.42 liter bottle of Thirster 100% prune juice approximately 1/2 full, open and not dated. During a surveyor observation of the main dining room kitchenette on 3/10/2025 at approximately 9:00 AM, the following was observed in the refrigerator: -One, 1/2 gallon container of whole milk, approximately half full, open and not dated. -One, 1.42-liter bottle of Thirster 100% prune juice approximately 1/2 full, open and not dated. -One, 20-ounce squeeze bottle of Welches concord grape jelly approximately half full, open and not dated. During a surveyor interview with the Food Service Director (FSD) at the time of the above observation, he revealed that he would expect food and beverages to be labeled and dated when opened. 2. The [NAME] Food Code 2018 Edition 3-302-12 Food Storage Containers, Identified with Common Name of Food states in part, .Except for containers holding Food that can be readily and unmistakably recognized .working containers holding Food or Food ingredients that are removed from their original packages for use .shall be identified with the common name of the Food . During a surveyor observation on 3/10/2025 at approximately 8:40 AM of the walk-in refrigerator in the main kitchen, revealed the following: -three white plastic tubes containing food in a metal container dated 3/9/2025, without a label. During a surveyor interview with the FSD at the time of the above observation, he revealed that the white plastic tubes were filled with ground beef. He further acknowledged that the tubes were not labeled with the name of the food. 3. Record review of the Rhode Island Food Code 2018 edition, Section 3-501.16 Time/Temperature Control for Safety, Hot and Cold Holding states in part, .(A) Except during preparation, cooking or cooling .time/temperature control for safety food shall be maintained: (1) At 57 degrees Celsius (135 degrees Fahrenheit [F]) or above . During a surveyor observation on 3/10/2025 at 12:03 PM, at the time the lunch meal was being plated in the kitchen, Dietary Cook, Staff J, obtained the temperature of the foods being served at the request of the surveyor. The steamed broccoli with butter was observed with the temperature of 102 F. During a surveyor interview on 3/10/2025 immediately following the above observation, Staff J, acknowledged that the broccoli was not at the safe hot holding temperature. He further acknowledged that he had already plated one resident's lunch plate that included the broccoli and did not obtain the temperatures of the food prior to plating the lunch meal. During a surveyor interview on 3/10/2025 at approximately 12:10 PM with the FSD, he acknowledged that the broccoli with butter was below the safe holding temperature of 135 F. Additionally, he indicated that he would expect the cook to obtain the temperature of all foods prior to plating.

Based on record review and staff interview, it has been determined that the facility failed to measure success and track performance of Quality Assurance and Performance Improvement (QAPI) actions to ensure that problem areas are identified, and good faith efforts for improvements are achieved and sustained demonstrated by measurable objectives with statistical data documented. Findings are as follows: Record review of the facility's 2025 QAPI plan states in part, .the QAPI Committee will utilize a formal and consistent methodology for planning, designing, measuring, assessing, and improving organizational performance and resident outcomes . Record review of the facility's 2024 and 2025 QAPI binder failed to reveal evidence of any actions, measurements, or tracking to ensure efforts for improvements of identified problem areas within the facility. During a surveyor interview on 3/12/2025 at approximately 12:30 PM with the Administrator, she acknowledged that the facility failed to develop actions, measurements, or tracking systems to measure and track performance of identified problem areas within the facility.

Based on record review and staff interview, it has been determined that the facility failed to complete an annual performance review for every nurse aide (NA) at least once every 12 months for 4 of 4 NA personnel records reviewed, Staff E, F, G, and H. Findings are as follows: Record review of the personnel files failed to reveal evidence that an annual performance evaluation was completed for the following NA's: -Staff E with a date of hire of 5/30/2023 -Staff F with a date of hire of 9/27/2021 -Staff G with a date of hire of 7/19/2021 -Staff H with a date of hire of 4/16/2023 During a surveyor interview on 3/12/2025 at approximately 10:00 AM with the Administrator, she was unable to provide evidence of a completed performance evaluation within the last 12 months for Staff E, F, G, and H.

Based on record review and staff interview, it has been determined that the facility failed to develop, implement, and maintain an effective training program for annual training for existing employees consistent with their expected roles, relative to education involving abuse, infection control, and dementia, per the facility assessment, for 8 of 10 employees reviewed, Staff E, F, G, H, J, K, L, and M. Findings are as follows: Review of the Facility Assessment, dated 1/1/2024, revealed in part, training topics are completed upon hire and annually for all staff, which include, but are not limited to, abuse and neglect, dementia management, and infection control. Record review revealed Nursing Assistant (NA), Staff E, was hired on 5/30/2023. Review of her training records failed to reveal evidence that she received annual education or training relative to abuse and neglect, or infection control. Record review revealed NA, Staff F, was hired on 9/27/2021. Review of his training records failed to reveal evidence that he received annual education or training relative to abuse and neglect, dementia management, or infection control. Record review revealed NA, Staff G, was hired on 7/19/2021. Review of her training records failed to reveal evidence that she received annual education or training relative to dementia management. Record review revealed NA, Staff H, was hired on 4/16/2023. Review of his training records failed to reveal evidence that he received annual education or training relative to abuse and neglect, dementia management, or infection control. Record review revealed Dietary Cook, Staff J, was hired on 10/25/2023. Review of his training records failed to reveal evidence that he received annual education or training relative to dementia management. Record review revealed NA, Staff K, was hired on 3/28/2024. Review of her training records failed to reveal evidence that she received education or training relative to abuse and neglect, dementia management, or infection control. Record review revealed Licensed Practical Nurse, Staff L, was hired on 3/18/2023. Review of his training records failed to reveal evidence that he received annual education or training relative to abuse and neglect or dementia management. Record review revealed Registered Nurse, Staff M, was hired on 2/17/2024. Review of her training records failed to reveal evidence that she received education or training relative to abuse and neglect, dementia management, or infection control. During a surveyor interview on 3/12/2025 at 3:28 PM with the Administrator, she indicated that she would expect that all training's outlined in the facility assessment should have been completed. Additionally, she was unable to provide evidence that the above-mentioned education and training's were completed for Staff E, F, G, H, J, K, L, and M, per the facility assessment. 46118

Based on record review and staff interview, it has been determined that the facility failed to provide written information to the resident or resident's representative that specifies the facility's bed-hold payment policy upon transfer to the hospital from the facility for 1 of 2 residents reviewed, Resident ID #42. Findings are as follows: Record review of a facility policy titled, Bed Hold Notification upon Transfer for hospitalization or upon Taking Therapeutic Leave revealed in part, .Procedure: Whenever a resident is sent to the hospital or takes a therapeutic leave as required by state and federal regulations. Procedure: A copy of the Resident Bed Hold Notice .is to be filled out with the resident's name and the date and time of the hospital transfer by the charge nurse who is preparing the transfer papers .Emergency transfer: a. A copy of the resident's Bed Hold Notice is to be attached to the resident's interagency transfer papers by the charge nurse .b. The person who is responsible for notifying the representative of the emergency transfer .will review the Resident Bed Hold Notice at the time and obtain .representative's decision concerning bed hold at that time .c. The representative response documentation is to be kept in the resident's medical record . Record review revealed that the resident was admitted to the facility in December of 2024 with a diagnosis including, but not limited to, congestive heart failure (a condition when the heart muscle is weakened and cannot pump blood effectively). Record review of the progress notes revealed that the resident was transferred to the hospital on December 16th, 2024. Further record review failed to reveal evidence that a bed hold policy was offered upon transfer to the hospital for Resident ID #42. During a surveyor interview on 3/11/2025 at 1:56 PM with the Administrator, she acknowledged that a bed hold notification was not completed, as required.

Based on record review and staff interview, it has been determined that the facility failed to ensure a resident is given the appropriate treatment and services to maintain his or her ability to carry out activities of daily living, for 1 of 1 resident reviewed with unwanted facial hair, Resident ID #94. Findings are as follows: Record review revealed the resident was admitted to the facility in January of 2025 with diagnoses including, but not limited to, pelvic fracture and osteoarthritis (a form of arthritis, commonly affecting the joints in the hands). Record review of an Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required supervision or touching assistance for personal hygiene. Further review revealed that assistance may be provided throughout the activity or intermittently. Surveyor observations on 3/10/2025 at 9:34 AM and 3/11/2025 at approximately 1:00 PM, revealed the resident was observed to have a moderate amount of facial hair to his/her chin, approximately a half an inch in length. During a surveyor interview immediately following the observation on 3/11/2025 at 1:01 PM with the resident, s/he revealed that they used to shave their chin, but has since lost his/her razor. The resident further revealed that no one at the facility has assisted them with shaving and that s/he would like their facial hair shaven. During a surveyor interview on 3/11/2025 at approximately 1:15 PM with Nursing Assistant, Staff A, she indicated that she should have assisted the resident with shaving. During a surveyor interview on 3/11/2025 at 1:21 PM with Registered Nurse, Staff B, after observing the resident, she acknowledged the resident's facial hair. Additionally, she indicated that shaving is part of resident care. During a surveyor interview on 3/11/2025 at approximately 2:00 PM with the Director of Nursing Services, she acknowledged that the resident should have been assisted with shaving.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, for 1 of 2 residents reviewed for hospitalization , Resident ID #7. Findings are as follows: Record review revealed the resident was readmitted to the facility in October of 2024 following a hospital stay where s/he was diagnosed with a fecal impaction (hardened stool accumulated in the rectum) and a urinary tract infection. Record review of the provider's progress note dated 10/19/2024 states in part, .Re-admission History and Physical .at [hospital], 9 cm [centimeter] ball of stool manually removed from resident, enema and bowel meds given . Record review of the physician's orders revealed an order dated 3/3/2022 which included the following: Bowel Protocol 1. Administer the Prune Juice if no bowel movement (BM) in 2 days 2. Give Milk of Magnesia (MOM) suspension by mouth for no BM in 3 days 3. Administer Dulcolax Suppository per rectum (PR) if no results from MOM by the next shift 4. Administer Fleet Enema PR if no results from suppository 5. Call the provider if there was no results from enema Record review of the bowel record documentation revealed the following: - 9/25/2024 through 10/15/2024 - revealed the resident had a medium BM on 9/25/2024. Documentation failed to reveal evidence that the resident had a subsequent BM until 10/2/2024, indicating s/he went 6 days without a BM. - 10/2/2024 through 10/3/2024 - revealed the resident had a BM on both days, however s/he did not have a subsequent BM until 10/7/2024, indicating the resident went without a BM for 3 days. - Documentation after 10/7/2024 failed to reveal evidence that the resident had a BM until 10/12/2024, indicating the resident went 4 days without a BM. - 10/12/2024 through 10/15/2024 failed to reveal evidence that the resident had a BM since 10/12/2024, indicating the resident went 3 days without a BM. Record review of the September and October 2024 Medication Administration Records (MARs), failed to reveal evidence that the resident was administered any of the bowel protocol medications from 9/26/2024 through 10/15/2024, as ordered. Record review revealed the resident was transferred to the hospital on 10/15/2024. During a surveyor interview on 3/12/2025 at 9:19 AM with Registered Nurse, Staff D, she was unable to provide evidence that the bowel protocol orders were administered according to the physician's order. During a surveyor interview on 3/12/2025 at 2:02 PM with the Director of Nursing Services, she revealed that the bowel protocol orders were not implemented according to the physician's order.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents with pressure ulcers receive the necessary treatment and services, consistent with professional standards of practice, to promote healing for 1 of 3 residents reviewed with a pressure ulcer (skin and tissue injuries caused by constant pressure to a specific area of the body), Resident ID #196. Findings are as follows: Record review revealed the resident was admitted to the facility in January of 2025 with a diagnosis including, but not limited to, pressure ulcer with unspecified stage. Record review of the wound specialist assessment dated [DATE] revealed the resident developed a stage 3 pressure wound (full-thickness skin loss where subcutaneous fat is visible) to the right ischium (lower back part of the hip bone). Further record review revealed a dressing treatment recommendation dated 3/4/2025 to apply a foam silicone dressing (a type of wound dressing) three times, weekly. Record review of a nursing progress note dated 3/5/2025 revealed that above treatment recommendation was reviewed by a provider and an order for the above recommendation was to be put in place. Record review of the March 2025 Treatment Administration Record failed to reveal evidence that the above treatment recommendation was implemented from 3/4/2025 until 3/11/2025, indicating that the resident did not have a treatment in place for his/her Stage 3 pressure wound for 7 days. During a surveyor interview on 3/12/2025 at 12:19 PM with the Director of Nursing Services, she acknowledged that the foam dressing treatment was not implemented until 7 days after the resident was seen by the wound specialist.

Based on record review and staff interview, it has been determined that the facility failed to ensure residents are free of any significant medication errors for 1 of 1 resident reviewed who was receiving the medication Victoza (an injectable medication prescribed to help lower blood sugars), Resident ID #30. Findings are as follows: Record review revealed the resident was admitted to the facility in January of 2024 with a diagnosis including, but not limited to, type 2 diabetes mellitus (high blood sugar caused by the body's inability to produce enough insulin). During the Resident Council Meeting on 3/11/2025 at 1:30 PM, it was revealed that Resident ID #30 did not receive his/her Victoza injection this past weekend. Record review revealed the following physician's orders: -7/3/2024 Humalog Insulin (insulin lispro) insulin pen; 100 unit/milliliter (mL); Amount to Administer: Per Sliding Scale; If Blood Sugar is less than 70, call MD. If Blood Sugar is 200 to 249, give 2 Units. If Blood Sugar is 250 to 300, give 4 Units. If Blood Sugar is 301 to 350, give 6 Units. If Blood Sugar is 351 to 400, give 8 Units. If Blood Sugar is greater than 400, call MD (medical doctor). -12/4/2024 for Victoza pen injector; 0.6 mg/0.1 mL (18 mg/3 mL); amt: 1.8 milligrams (mg) subcutaneous daily in the PM. Record review of the March 2025 Medication Administration Record (MAR) failed to reveal evidence that the Victoza medication was administered on 3/8/2025 or 3/9/2025 as ordered. Further review of the MAR revealed the medication was unavailable and that the medication was ordered from the pharmacy on 3/8/2025. Additional review of the MAR revealed the following elevated blood sugars (BS) and dates and times when the resident was administered extra units of insulin: -3/9/2025 between 11 AM - 1 PM, the resident's BS was 400, 8 units of insulin per the sliding scale. -3/10/2025 between 11 AM - 1 PM, the resident's BS was 540, an extra 6 units of insulin was ordered, in addition to the sliding scale for a total dose of 14 units. -3/11/2025 between 11 AM - 1 PM, the resident's BS was 416, an extra 4 units of insulin was ordered, in addition to the sliding scale for a total dose of 12 units. Record review of the nursing progress notes failed to reveal evidence that the provider was notified that the Victoza was unavailable for administration on 3/9/2025. During a surveyor interview on 3/12/2025 at 1:27 PM with a pharmacy staff member, she revealed that there was no record that the Victoza medication was ordered until 3/10/2025. During a surveyor interview on 3/12/2025 at approximately 2:45 PM with Licensed Practical Nurse, Staff I, she revealed that she did not notify the provider on 3/9/2025 that the Victoza was not available for administration. During a surveyor interview with the Director of Nursing Services on 3/12/2025 at 1:54 PM and at 3:00 PM, she acknowledged that the resident did not receive his/her Victoza on 3/8 and 3/9/2025 as ordered.

Based on record review and staff interview if has been determined that the facility failed to provide treatment and care in accordance with professional standards of practice and failed to promptly identify and intervene during an acute change in a resident's condition, related to vomiting and an unknown cardiac event for 1 of 1 resident reviewed, Resident ID #38. Findings are as follows: Review of a facility policy titled, Resident Change in Condition dated [DATE] states in part, .Changes in condition require assessment by the RN [registered nurse] and notification to the MD [Medical Doctor] (both to be done timely). Timely depends upon the level/severity of the change and RN should use professional assessment and judgement to make that decision. Timely is certainly no later than the shift of the change . Record review of a closed record revealed that Resident ID #38, was admitted to the facility in July of 2020 with diagnoses including, but not limited to, vascular dementia and nontraumatic intracerebral hemorrhage (emergency condition in which a blood vessel in the brain ruptures and causes bleeding inside the brain). Review of the progress notes revealed the following: [DATE] at 9:39 PM - Yelling out for assist. 1 episode of vomiting. Vitals stable, taking fluids well. Rapid covid negative. [DATE] at 6:20 AM - Reported from previous shift res [resident] had diarrhea and vomiting previous shift. Res vomited large amount of undigested food x 3. No further diarrhea. Res pale, tired. HOB [head of bed] elevated. Repositioned to side. Call light within reach. Frequent checks [DATE] at 8:21 AM - PT [patient] found unresponsive [at] 7:43am, prior to unresponsive pt was alert, talking and able to make needs known, no complaints. unable to find pulse at that time, CPR [cardiopulmonary resuscitation] started and 911 was called at 7:47am. 911 in and CPR continued, pt is being transferred to [hospital] . Review of the emergency room documentation dated [DATE] at 8:47 AM revealed that the resident had been transferred to the hospital by Emergency Medical Services (EMS) after being found unresponsive and CPR being administered. Additionally, it revealed that when EMS initially assessed the resident s/he was found to be in ventricular fibrillation (life threatening heart rhythm that results in a rapid, inadequate heartbeat). Further review revealed that due to the resident remaining in persistent asystole (heart stops pumping) in the setting of an unwitnessed cardiac arrest, resuscitation efforts were terminated and the resident was declared dead at 8:36 AM. Record review failed to reveal evidence of an assessment completed to include complete vital signs on [DATE] during the 3:00 PM to 11:00 PM shift although the resident had vomited. Further review failed to reveal evidence that a doctor had been notified of the resident's vomiting. During a surveyor interview on [DATE] at 11:45 AM with the Director of Nursing Services (DNS), she acknowledged that she was the nurse on duty on [DATE] during the 3:00 PM to 11:00 PM shift. Additionally, she revealed that she did obtain the residents vital signs however, she did not document them. The DNS further acknowledged that she did not complete a full assessment and did not report the resident vomiting to the physician. Additional record review failed to reveal evidence of an assessment completed to include complete vital signs on [DATE] during the 11:00 PM to 7:00 AM shift although the resident had vomited 3 times and appeared pale and tired. Further review failed to reveal evidence that a doctor had been notified of the residents change in condition. During a surveyor interview on [DATE] at 3:10 PM with RN, Staff A, she revealed that she was the nurse on the 11:00 PM to 7:00 AM shift on [DATE]. Additionally, she revealed that the resident was uncomfortable on her shift and was vomiting. Staff A acknowledged that she did not complete a full assessment to include vital signs and she did not report the resident's vomiting to the physician. Furthermore, she revealed that she would have reported abnormal vital signs to the physician but she did not obtain them. During a surveyor interview on [DATE] at 12:30 PM with Nurse Practitioner (NP), Staff B, she revealed that she would consider a resident vomiting a change in condition and would expect the staff to notify her of the change. Additionally, she revealed that if she had been aware of the resident vomiting, she would have ordered the staff to perform an assessment to include a complete set of vital signs. During a surveyor interview on [DATE] at 9:30 AM with the DNS she was unable to provide evidence that the staff completed an assessment after a change in condition or reported the change in condition to the physician by the end of each shift per the policy. The facility's failure to perform an assessment of a resident including vital signs with multiple episodes of vomiting and failure to promptly identify and intervene during an acute change in a resident's condition had the potential to result in the resident's harm or death. 46715

Based on record review, surveyor observation and staff interview it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to Respiratory Syncytial Virus (RSV) for 1 of 2 nursing units and affecting Resident ID #s 1,2,3,4,5, 6 and 7. Findings are as follows: Review of the Centers for Disease Control and Prevention (CDC) Appendix A, Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) revealed precautions for RSV should include standard, droplet and contact precautions throughout the duration of the illness. Review of a facility policy titled, Isolation last reviewed ,d+[DATE] revealed in part, It is the policy of this facility to prevent the spread of infection within the facility through the use of isolation precautions .Transmission Based Precautions, as defined by the CDC, will be employed for known or suspected infections for which the route of transmission/prevention is known . Review of a facility provided document titled, RSV in Adults states in part, .RSV can survive up to 6 hours on surfaces, from cloth gowns and paper tissue for ,d+[DATE] min [minutes], and from skin for up to 20 minutes. Good hand hygiene and environmental cleaning is very important to prevent the spread. 1. Record review revealed that Resident ID #2 was admitted to the facility in November in 2023 with diagnoses including, but not limited to, chronic obstructive pulmonary disease and compression fracture of the vertebrae. Review of a progress note dated [DATE] revealed that the resident had abnormal lung sounds with a fever of 102.2 degrees (normal 97XXX,d+[DATE].3), pulse of 156 beats per minute (bpm) (normal ,d+[DATE] bpm) and a pulse oximetry level of 85% (normal ,d+[DATE]) on 4 liters of oxygen. Additionally, it revealed that the resident was transferred to the hospital. Review of a hospital Discharge Summary Final Report dated [DATE] revealed that the resident was admitted to the hospital with positive RSV, bacterial pneumonia, and septic shock on [DATE]. Further review revealed the resident expired on [DATE]. Review of a facility provided document titled, Respiratory Illness Outbreak: Cumulative Line List for Residents dated [DATE] failed to reveal that Resident ID #2 was on the facility line list for RSV. 2. Record review revealed Resident ID #1 was admitted to the facility in October of 2021 with diagnoses including, but not limited to, hypertension and heart failure. Review of a facility provided document titled, Respiratory Illness Outbreak: Cumulative Line List for Residents dated [DATE] revealed Resident ID #1's date of illness onset was [DATE]. Additional record review of a clinical laboratory final report dated [DATE] revealed s/he is positive for RSV. Review of a physician's order dated [DATE] states in part, symptom monitoring for Covid 19: Assess for fever respiratory symptoms (cough, new or worsening, SOB [shortness of breath], sore throat .If symptoms are present initiate contact/droplet precautions . During a surveyor observation on [DATE] at 10:21 AM of the resident's room revealed a sign for droplet precautions for staff entering the room to wear eye protection and a mask. The signage failed to include the need for a gown and gloves per the CDC guidance. During the same surveyor observation, 2 staff members, Staff E and Staff F were observed in the residents room with only a surgical mask in place. During a surveyor interview directly following the above observation with Certified Nursing Assistant (CNA), Staff E, she revealed that she only was required to wear a surgical mask and her personal glasses in the room. Additionally, she was unable to tell the surveyor what the resident was on precautions for. During a subsequent interview with Housekeeper, Staff F, she acknowledged that she did not have the appropriate personal protective equipment (PPE) per the sign on the door. Additionally, she was unable to tell the surveyor what the resident was on precautions for. During a surveyor interview on [DATE] at 10:57 AM with the Infection Preventionist (IP) and the Director of Nursing Services (DNS) they were unable to provide evidence that the staff were wearing the proper PPE for a resident with positive RSV. Additionally, they acknowledged that the precautions of only droplet precautions were not adequate to prevent the spread of RSV per the CDC guidelines. 3. Record review revealed that Resident ID #3 was readmitted to the facility in November of 2023 with diagnoses including, but not limited to, dementia, asthma, and pneumonia due to inhalation of food or vomit. Review of a facility provided document titled, Respiratory Illness Outbreak: Cumulative Line List for Residents dated [DATE] revealed Resident ID #3's date of illness onset was [DATE]. Review of a physician's order dated [DATE] states in part, symptom monitoring for Covid 19: Assess for fever respiratory symptoms (cough, new or worsening, SOB [shortness of breath], sore throat .If symptoms are present initiate contact/droplet precautions . Review of a progress note dated [DATE] revealed the resident had a fever of 101.5 degrees and a pulse oximetry level of 88% without oxygen. Review of a progress note dated [DATE] revealed s/he required 3 liters of oxygen to maintain an oxygen saturation level of 94%. Review of a clinical laboratory final result document dated [DATE] revealed s/he is positive for RSV. During a surveyor observation on [DATE] at 10:17 AM of the residents room revealed signage for droplet precautions and staff must wear eye protection and a mask. The signage failed to include the need for a gown and gloves per the CDC guidance. During the above surveyor observation, a Speech Therapist, Staff G, was observed in the residents room with only a surgical mask in place. Staff G failed to wear the appropriate PPE to prevent the spread of RSV including a gown, eye protection and gloves. Staff G acknowledged she was not wearing the PPE per the signage on the door. During a surveyor interview on [DATE] at 10:19 AM with RN, Staff H, she revealed that the staff should be wearing respiratory precautions in the resident's rooms with symptoms to include a gown, mask and eye protection. 4. Record review revealed that Resident ID #6 was admitted to the facility in [DATE] with diagnoses including, but not limited to, left femur fracture and pneumonia due to inhalation of food or vomit. Review of a physician's order dated [DATE] states in part, symptom monitoring for Covid 19: Assess for fever respiratory symptoms (cough, new or worsening, SOB [shortness of breath], sore throat .If symptoms are present initiate contact/droplet precautions . Review of a progress note dated [DATE] revealed the resident was transferred to the hospital secondary to increased white blood cell count. Review of a progress note dated [DATE] revealed the resident was admitted to the hospital with septic shock due to positive RSV. Review of a facility provided document titled, Respiratory Illness Outbreak: Cumulative Line List for Residents dated [DATE] revealed Resident ID #6 was not listed on the line list. 5. Record review revealed that Resident ID #4 was admitted to the facility in December of 2023 with diagnoses including, but not limited to, dementia and chronic kidney disease. Review of a facility provided document titled, Respiratory Illness Outbreak: Cumulative Line List for Residents dated [DATE] revealed Resident ID #4's date of illness onset was [DATE]. Review of a physician's order dated [DATE] states in part, symptom monitoring for Covid 19: Assess for fever respiratory symptoms (cough, new or worsening, SOB [shortness of breath], sore throat .If symptoms are present initiate contact/droplet precautions . Review of a progress note dated [DATE] revealed the resident was in respiratory distress with use of accessory muscles to breath and pulse oximetry level of ,d+[DATE]% on room air. Review of a progress note dated [DATE] revealed the resident required 5 liters of oxygen to maintain an oxygen saturation level of 91%. During a surveyor observation on [DATE] at 10:17 AM, of the resident's room revealed signage for droplet precautions and staff must wear eye protection and a mask. The signage failed to include the need for a gown and gloves per the CDC guidance. During the above surveyor observation Staff G was observed in the residents room with only a surgical mask in place. Staff G failed to wear the appropriate PPE to prevent the spread of RSV including a gown, eye protection and gloves. Staff G acknowledged that she was not wearing the PPE per the signage on the door. During a surveyor interview on [DATE] at 10:19 AM with Staff H, she revealed that the staff should be wearing respiratory precautions in the resident's rooms with symptoms to include a gown, mask and eye protection. Review of a clinical laboratory final result document dated [DATE] revealed s/he is negative for RSV however, continues with abnormal respiratory symptoms. 6. Record review revealed that Resident ID #5 was admitted to the facility in December of 2023 with diagnoses including, but not limited to, weakness and Alzheimer's disease. Review of a facility provided document titled, Respiratory Illness Outbreak: Cumulative Line List for Residents dated [DATE] revealed Resident ID #5's date of illness onset was [DATE]. Review of a physician's order dated [DATE] states in part, symptom monitoring for Covid 19: Assess for fever respiratory symptoms (cough, new or worsening, SOB [shortness of breath], sore throat .If symptoms are present initiate contact/droplet precautions . Review of a progress note dated [DATE] revealed the resident's oxygen saturation level was ,d+[DATE]% on room air. Further review revealed the resident required humidified oxygen at 4.5 liters to maintain an oxygen saturation level at 92%. During a surveyor observation on [DATE] at 10:12 AM revealed signage for droplet precautions and staff must wear eye protection and a mask. The signage failed to include the need for a gown and gloves per the CDC guidance. During the above surveyor observation, a Housekeeper, Staff I was observed in the resident's room with a gown, gloves, and surgical mask but without eye protection. During a surveyor interview immediately following the observation Staff I acknowledged that she was not wearing eye protection as the signage states. Additionally, she was unable to tell the surveyor why the resident was on precautions but only that it is not Covid. During a surveyor interview on [DATE] at 10:19 AM with Staff H, she revealed that the staff should be wearing respiratory precautions in the resident's rooms with symptoms to include a gown, mask and eye protection. Review of a clinical laboratory final result document dated [DATE] revealed s/he is negative for RSV however, continues with abnormal respiratory symptoms. 7. Record review revealed that Resident ID #7 was admitted to the facility in November of 2023 with diagnoses including, but not limited to, asthma and urinary tract infection. Review of a physician's order dated [DATE] states in part, symptom monitoring for Covid 19: Assess for fever respiratory symptoms (cough, new or worsening, SOB [shortness of breath], sore throat .If symptoms are present initiate contact/droplet precautions . Review of a progress note dated [DATE] revealed the resident began with a moist nonproductive cough. During a surveyor observation on [DATE] at 8:25 AM the resident was in bed and noted to be coughing. Further observation failed to reveal evidence that the resident had been placed on contact or droplet precautions. During a surveyor interview on [DATE] at approximately 8:30 AM with the DNS, she acknowledged the resident's respiratory symptoms and revealed that the practitioner was made aware and ordered for Covid testing. Review of a clinical laboratory final result document dated [DATE] revealed s/he is positive for RSV. During a surveyor interview on [DATE] at approximately 2:30 PM with the DNS in the presence of the Administrator, she acknowledged the incorrect signage and PPE use to prevent the spread of RSV per CDC guidelines. As a result of the facility's failure to promptly identify respiratory symptoms in ill residents and properly follow the CDC guidance relative to RSV precautions this facility is currently experiencing an RSV outbreak with death resulting. 50004

46240 Based on record review and staff interview, it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight, and failed to follow their policy relative to weight and weight change for 2 of 9 residents reviewed, Resident ID #s 206 and 304. Findings are as follows: Review of the facility policy titled, Weight and Weight Change states in part, .Policy: Resident weight will be obtained upon admission, weekly x [times] 4, and then at least monthly and recorded in the medical record. Significant weight changes will be addressed by the interdisciplinary care team .4. The weight change report will be audited regularly for significant changes (e.g. [for example], > [more than] 5% in 30 days, > 7.5% in 90 days, >10% in 180 days), and staff will reweigh the resident if applicable. 5. Residents with significant weight changes will be assessed by the IDT [interdisciplinary team] and appropriate recommendations will be documented in the medical record. 1. Record review for Resident ID #206 revealed the resident was readmitted to the facility in December of 2022 with diagnoses including, but not limited to, osteomyelitis of vertebra (infection of the backbone) and failure to thrive. Review of the resident's weight record revealed the following weights: -12/20/2022 226 pounds (lbs.) -12/27/2022 224 lbs. -1/10/2022 206.4 lbs. -1/14/2023 204.2 lbs. Further record review revealed the resident lost 21.8 lbs. from 12/20/2022 to 1/14/2023, which is a significant weight loss of 9.65%. Record review failed to reveal that the physician or dietitian were notified of the above-mentioned weight loss. Record review of an initial nutritional assessment dated [DATE] documented by the Registered Dietitian (RD), failed to reveal evidence that the resident's weight loss of 21.8 lbs. was addressed. During a surveyor interview on 2/10/2023 at 10:30 AM with the RD, she indicated that she was not aware of the weight loss and could not explain why the resident's significant weight loss was not addressed during the initial nutritional assessment or thereafter. She further stated, my fault. Record review of a progress note dated 2/10/2023 at 12:47 PM authored by the RD, after being made aware of the weight loss by the surveyor, revealed in part, .[resident] has lost approximately 30 # [pounds] since .admission to the facility . 2. Record review for Resident ID #304 revealed the resident was readmitted to the facility in January of 2023 with a diagnosis including, but not limited to, nutritional deficiency. Review of the facility policy titled, Weight and Weight Change states in part, Each resident's weight .will be obtained upon admission and recorded in the medical record . Record review failed to reveal an admission weight for the resident. Further review revealed a baseline weight of 133 lbs., obtained on 1/18/2023 and recorded 1/27/2023 by Registered Nurse, Staff C. During a surveyor interview on 2/10/2023 at 1:15 PM with Staff C, she acknowledged an admission weight was not obtained for the resident per the facility policy. Additionally, she revealed that the documented weight on 1/18/2023 was taken directly from the hospital admission documentation, and the resident's weight was not obtained at the facility, per facility policy.

Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident receives adequate supervision and assistance to prevent accidents for 1 of 7 residents reviewed for safe patient handling, Resident ID #1. Findings are as follows: Review of the facility policy titled Policy for Safe Handling of Residents states in part, All residents will be safely transferred without any injuries . All residents will be monitored daily as to their mobility and any changes will be reported to the charge nurse. The charge nurse will assess each resident that is brought to their attention and a nurses' note will be written as to any changes in mobility and/or lifting, transferring and repositioning requirements . All modes of transfer will be reviewed as needed and the safest mode will be used for each resident, so that any injury will be prevented. Record review revealed that the resident was admitted to the facility in October of 2020, with diagnoses that include but are not limited to, difficulty swallowing following a stroke and malignant neoplasm (tumor) of the scapula, kidney, and long bones of the upper arm. The resident was admitted to hospice services in December of 2020 following a decline in status. Review of a quarterly Minimum Data Set assessment dated [DATE] revealed the resident's cognitive status was moderately impaired, s/he required extensive assistance with transferring and was receiving hospice services. Further record review revealed a nursing progress note written by Licensed Practical Nurse, Staff D, dated [DATE] at 9:12 PM, which stated the resident was having difficulty with transferring. Hoyer [mechanical] lift for transfer . During an interview with Staff D, on [DATE] at 3:00 PM, she stated upon her assessment of the resident on [DATE], s/he was weak and frightened to stand up. She stated she needed to use the mechanical lift to transfer the resident due to weakness, which was a change from his/her usual level of functioning. She stated that she documented this assessment in her progress note as stated above and verbally reported this to the next nurse (Registered Nurse, Staff A). She further stated she completed a request for rehabilitation staff to screen the resident due to a change in functional status. Record review of a nursing progress note written by Registered Nurse, Staff A dated [DATE] at 4:28 AM revealed in part, .Resident calling out .decided to bring [resident] to nurses station .lifted from under arms and tried to move [resident] back to chair and instead had to lower to the floor. LUA [left upper arm] bleeding from skin tear already present and began bleeding with trying to move arm .could not move r [right] arm. Wanted rescue . During an interview with Nursing Assistant, Staff B, on [DATE] at 7:00 AM, she revealed that on the night of the incident, she reported to Staff A, that the resident was becoming agitated, yelling out, which was unusual for this resident. She stated Staff A asked her to get the resident into the wheelchair and bring him/her to the nurse's station. Staff B stated she asked Nursing Assistant, Staff C, for help with the transfer. Staff B further stated, after she and Staff C provided incontinent care to the resident Staff C went to get a wheelchair. During an interview with Staff C on [DATE] at 6:45 AM, she revealed she overheard the nurse to nurse report between Staff A and Staff D at change of shift on [DATE]. Staff C stated she didn't feel it was safe to transfer the resident to the wheelchair as s/he was weak and needed the mechanical lift the previous shift. She then stated Staff B proceeded to lift the resident out of the bed. The resident was not able to bear weight and both Staff B and Staff C proceeded to lower him/her to the floor. A telephone interview was conducted on [DATE] at 9:42 AM with Staff A, who was present at the time of the incident. She stated it was reported to her by Staff B that the resident was agitated. She then asked Staff B to get the resident out of bed and bring him/her to the nurse's station. Staff A stated she did not assess the resident prior to asking Staff B to get the resident out of bed. Staff A stated she heard a commotion and entered the room. Staff B and Staff C had lowered the resident to the floor. Staff A further stated that when she entered the room Staff B and Staff C were attempting to lift the resident from under his/her arms from the floor and were unable to do so. During the attempted transfer, Staff A witnessed the residents skin lift from his/her arm at the shoulder. Staff A then directed Staff B and Staff C to lower the resident back to the floor. The resident stated s/he could not move his/her right arm and wished to be taken to the hospital. Staff A stated 911 was called and the resident was sent to the hospital. Staff A acknowledged that she did recall being told by Staff D that the resident was very weak. Review of the hospital records dated [DATE] revealed the resident sustained a near degloving (the top layers of your skin and tissue are ripped from the underlying muscle, connective tissue, or bone) of the right arm and a fracture of the right humerus (long bone of the upper arm). It was determined given the residents co-morbidities and not being a surgical candidate that the resident was sent to an inpatient hospice facility and later expired with a diagnosis sequale of right humerus fracture. Review of a medical examiner's report dated [DATE] revealed the resident expired at an inpatient hospice facility on [DATE] with a cause of death, sequelae (a condition which is the consequence of a previous injury) of a right humerus fracture. During an interview with the Assistant Director of Nursing on [DATE] at 1:15 PM, she stated she would have expected Staff A to assess the resident, due to the resident's agitation, prior to instructing Staff B to transfer the resident out of bed. The facility could not provide evidence that the resident received adequate assistance to prevent accidents.