Every finding on record at The Dawn Hill Home for Rehab and Healthcare

Based on clinical record review and staff interview the facility failed to provide appropriate treatment and services for 1 of 1 resident reviewed with an indwelling foley catheter (a flexible tube that collects urine from the bladder and empties the urine into a drainage bag), Resident ID #14.Findings are as follows:Record review revealed the resident was admitted to the facility in January of 2026 with diagnoses including, but not limited to, obstructive uropathy (a structural or functional hindrance of normal urine flow) and urinary retention.Record review of a hospital discharge document titled, Discharge summary dated [DATE] revealed the resident was treated for a catheter associated urinary tract infection with an order for a urology follow-up and consideration of a Transurethral Resection of the Prostate (TURP, a surgical procedure to remove excess prostate tissue through the urethra to relieve urinary problems).Record review revealed that the resident's hospital Discharge summary, dated [DATE] revealed the resident was treated for a catheter associated urinary tract infection with an order which states, .already have urology referral from previous discharge .Review of a physician progress note dated 4/5/2026 revealed that the resident was assessed related to his/her recent admission to the hospital with a diagnosis of encephalopathy (abnormal brain function, leading to altered mental states and cognitive impairment) due to a urinary tract infection and a urology referral was ordered.Record review revealed the following Nurse Practitioner notes:4/8/2026 revealed the resident was seen by the provider for an acute visit which states in part, .being started on Bactrim DS (an antibiotic) orally twice daily for 5 days for urinary tract infection.***follow-up***.Urology referral pending.4/15/2026 revealed the resident has a urology appointment scheduled for this morning.Record review failed to reveal evidence that the resident went to his/her urology appointment on 4/15/2026.Review of a nursing progress note dated 4/17/2026 revealed that the resident had a urology appointment rescheduled for 5/5/2026.Review of a nursing progress note dated 5/5/2026 revealed that the resident was unable to be seen by the Urologist and an appointment needs to be rescheduled in the morning.Record review revealed the following Nurse Practitioner notes:5/8/2026 states in part, .Reschedule urology outpatient appointment (canceled this week) .5/11/2026 states in part, .Urology outpatient appointment needs to be scheduled.5/19/2026 states in part, .Urology outpatient appointment still needs to be scheduled. 5/29/2026 states in part .Urology outpatient appointment still needs to be scheduled.***follow-up***.Urology outpatient appointment - needs to be scheduled.During a surveyor interview on 6/3/2026 at 9:09 AM with the Facility Scheduler, she revealed that the resident's urology appointment had not been scheduled. Review of a nursing progress note dated 6/3/2026 at 10:57 AM, revealed that the resident has a urology appointment scheduled for 6/10/2026 at 9:30 AM scheduled after it was brought to the facility's attention by the surveyor.During a surveyor interview on 6/3/2026 at 1:16 PM, with the Director of Nursing Services, she revealed that she would have expected the resident's urology appointment to be rescheduled immediately after the 5/5/2026 appointment was canceled.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that services were provided in accordance with professional standards of quality by failing to implement and follow physician orders. Specifically, the facility failed to follow a physician's order for a cancer center referral for 1 of 1 resident reviewed, Resident ID #102, and failed to appropriately manage and follow physician orders related to a peripherally inserted central catheter (PICC) line-a thin, flexible tube inserted into a peripheral vein in the upper arm and advanced to a large central vein near the heart-for 1 of 1 resident reviewed with a PICC line, Resident ID #138. Findings are as follows:1. According to Mosby's 4th Edition, Fundamentals of Nursing page 314, which states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.Record review revealed Resident ID #102 was admitted to the facility in August of 2022 with diagnoses including, but not limited to, dementia and chronic kidney disease.Review of the quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 3 out of 15, indicating severe cognitive impairment.Review of a skin assessment dated [DATE] revealed an inverted nipple and drainage of the left breast.Record review revealed the following Nurse Practitioner notes:5/19/2026- a left-sided inverted nipple with drainage noted on the inside with a pea-sized nodule at approximately the 3 o'clock position of the left breast. An ultrasound of the area was ordered.5/20/2026- ultrasound of the left breast completed with results confirming a nodule measuring 4 millimeters (mm) by 4 mm by 3 mm in the 3 o'clock position. Goals of care were discussed with the resident's family member and a consult with the cancer center for further evaluation and treatment was ordered. The facility is to schedule and arrange for transport. Record review revealed a physician's order dated 5/20/2026 for a breast consultation.Record review failed to reveal evidence that an appointment with the cancer center was scheduled or completed as ordered. During a surveyor interview on 6/2/2026 at approximately 1:15 PM with the South Unit Manager, Staff B, she acknowledged that the resident had not followed up with the cancer center and that an appointment had not been scheduled.During a surveyor interview on 6/2/2026 at 1:18 PM with the scheduler, she acknowledged that she received the physician's order to schedule the cancer center appointment on 5/20/2026; however, she did not schedule the appointment for the resident.During a surveyor interview on 6/3/2026 at 1:38 PM with the Director of Nursing Services (DNS), she revealed that she would have expected the cancer center appointment to have been scheduled as ordered as soon as possible.2. Review of the facility policy titled, Vascular Access Devices and Infusion Therapy Procedures Peripherally Inserted Central Line Catheter (PICC) dated 10/24, states in part, .measure arm circumference of upper arm.on admission as a baseline.10 cm (centimeters) above the insertion site.Measure external length of PICC catheter.on admission, with each dressing change, and when clinically indicated.Record review revealed Resident ID #138 was admitted to the facility in May of 2026 with diagnoses including, but not limited to, pneumonitis (a condition characterized by swelling and irritation of the lung tissue) and surgical aftercare following surgery on the digestive system.Review of the PICC Insertion Record dated 5/23/2026 revealed the PICC line was inserted on 5/23/2026 into the right arm with an external length of 0. Further review revealed the resident's arm circumference measured 25 cm.Review of the NSG Admission/readmission Evaluation (RI and NH) - V2 dated 5/27/2026 failed to reveal evidence that the PICC line was noted, assessed, or that the resident's arm circumference and external catheter length was measured. Record review failed to reveal evidence that a care plan was in place pertaining to PICC line care.Record review of the progress notes revealed the resident's PICC line dressing was changed on 5/28/2026. Further review failed to reveal evidence that the resident's arm circumference measurement was obtained. During a surveyor observation on 6/3/2026 at 1:29 PM, the resident's PICC line dressing was intact and dated 6/1/26.Record review failed to reveal documentation that the PICC line dressing had been changed on 6/1/2026, measurement of the external catheter length, or measurement of the resident's arm circumference was obtained, until after it was brought to the facility's attention by the surveyor on 6/3/2026.During a surveyor interview on 6/3/2026 at 11:14 AM with North Wing Manager, Staff A, she revealed that the PICC line external catheter length should be measured when the dressing is changed. During a surveyor interview on 6/3/2026 at 12:58 PM with East Unit Manager, Staff C, she revealed that she changed the resident's PICC line dressing on 6/1/2026 due to the edges of the dressing lifting. Additionally, she revealed that she did not receive a physician's order or document the dressing change, the external catheter length, or the resident's arm circumference measurement until 6/3/2026 at 12:24 PM. This documentation was entered into the electronic medical record 2 days after the dressing change and after the surveyor interviewed staff regarding concerns with Resident ID #138's PICC line assessments and documentation. During a surveyor interview on 6/3/2026 at 1:42 PM with the DNS, she revealed that she would expect the PICC line external catheter length and the arm circumference measurements to be obtained and documented on admission and when dressing changes are completed. She further revealed that she would expect nursing notes to be completed timely, usually prior to the end of the nurse's shift. Additionally, she revealed that she would expect a care plan to be in place pertaining to the PICC line.Record review revealed late entry progress notes were entered into the electronic medical record on 6/3/2026 to include PICC line external measurements and arm circumference measurements, after it was brought to the facility's attention by the surveyor.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 26 opportunities for error observed during the medication administration task, there were 2 errors resulting in an error rate of 7.69% affecting Resident ID #s 51 and 75.Findings are as follows:Review of a facility policy titled, Medication Administration General Guidelines dated February 2026, states in part, .Medication Preparation: Prior to administration, review and confirm medication orders for each individual client on the Medication Administration Record (MAR). Compare the medication and dosage schedule on the client's MAR with the medication label.Medications are administered in accordance with written orders of the prescriber.1. Record review revealed Resident ID #75 has a physician's order for Miralax (a medication prescribed to treat constipation) oral powder 17 Gram two times a day, dilute with at least 4 ounces (oz) of fluid.During a surveyor observation during the medication administration task on 6/2/2026 at 9:00 AM with Certified Medication Technician (CMT), Staff D, she was observed diluting the resident's Miralax in a 7 oz cup that was filled at approximately 1/3 of the cup (approximately 3 oz) with water, without measuring the water prior to diluting the Miralax. Staff D attempted to administer the medication to the resident before being stopped by the surveyor.During a surveyor interview immediately following the above-mentioned observation, she acknowledged that she did not dilute the Miralax in the required amount of fluids, as ordered. Additionally, Staff D stated that she was unsure of how to measure the 4 oz of fluids that was ordered. 2. Record review revealed Resident ID #51 has a physician's order for Senna Plus (a medication prescribed to treat constipation) 8.6-50 milligram, give two tablets by mouth daily. During a surveyor observation during the medication administration task on 6/2/2026 at 9:09 AM with CMT, Staff E, she was observed administering one tablet of Senna Plus instead of two tablets, as ordered.During a surveyor interview immediately following the above-mentioned observation, she acknowledged that she administered one tablet instead of two, as ordered.During a surveyor interview on 6/3/2026 at 2:32 PM with the DNS, she indicated that she would expect the staff to follow all physician's orders including all instructions when administering medications to the residents.

Based on clinical record review and staff interview, the facility failed to ensure that an injury of unknown origin was thoroughly investigated for 1 of 1 resident reviewed who sustained fractures to his/her right ankle, Resident ID #1. Findings are as follows:Record review of a community-reported complaint submitted to the Rhode Island Department of Health on 3/19/2026 alleged that the resident sustained an injury of unknown origin and that the resident's representative was not informed of the injury or the possible cause.Record review revealed the resident was admitted to the facility in October of 2025 with a diagnosis including, but not limited to, Alzheimer's disease. The resident was admitted to the facility while receiving and continues to receive hospice services (a specialized care for individuals with a terminal illness who are approaching the end of life). Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident is non-ambulatory (a person who is unable to walk) and is dependent on staff for all transfers. Review of a Brief Interview for Mental Status Assessment revealed the resident have severe cognitive impairment.Record review of a progress note authored by Registered Nurse (RN), Staff A, dated 3/9/2026 at 2:40 PM, revealed the resident exhibited grimacing after being brought to the dining room by the staff. Further review of the notes revealed the resident was found to have swelling and bruising to his/her right ankle. An order was obtained for an x-ray of the right foot and ankle.Record review of an x-ray report dated 3/9/2026 at 11:33 PM confirmed an acute to subacute fractures of the medial malleolus with displacement and a moderately displaced fracture of the lateral malleolus.Record review failed to reveal evidence that the facility conducted a thorough investigation into the circumstances surrounding the resident's injury. Furthermore the record lacked documentation by the provider or staff determining potential causes of the injury or the identification of cause of the injuries. Additional record review failed to reveal evidence that the facility implemented interventions to prevent further/potential injuries to the resident.Record review of a progress note authored by Nurse Practitioner, Staff B, dated 3/10/2026 at 12:15 AM, revealed that the X-ray results identified an acute to subacute fracture of the medial malleolus (the inner ankle) and an acute to subacute moderately displaced fracture of the lateral malleolus (the outer ankle).During a surveyor interview on 3/24/2026 at 12:24 PM with hospice aide, Staff C, she stated that she had taken the resident into his/her room after lunch to provide care accompanied by two facility staff, Nursing Assistants, Staff D and Staff E. Staff C stated that the resident did not exhibit discomfort prior to care; however, during care, the resident became agitated and flailed his/her upper and lower extremities. She stated that Staff D held down the resident's legs and Staff E held down the resident's arms while care was completed. Staff C acknowledged she did not stop care when the resident became agitated and did not notify the nurse on duty of the resident's behavior. She stated that after care was provided, the resident was transferred to a chair and was taken back to the dining room. Staff C stated that she left the unit for her lunch break and upon her return, she learned the resident had a swollen ankle. She stated she did not know how the injury occurred.During an interview on 3/24/2026 at 1:24 PM, RN, Staff A, she acknowledged that she was the nurse on duty when the resident's right ankle was observed to be swollen and bruised. She revealed that she had called the provider and informed them of the injury that was observed and obtained the order for x-rays. Additionally, she was unable to provide evidence that an investigation into the origin of the injuries had been conducted.During surveyor interviews on 3/24/2026 at 12:07 PM and at 1:58 PM, with the Director of Nursing Services, she was unable to provide evidence that a thorough investigation was conducted, that measures were implemented to prevent further potential injury, or that investigative findings were reported in accordance with regulatory requirements.During a surveyor interview on 3/24/2026 at 2:05 PM with Nurse Practitioner, Staff F, she revealed that she was made aware of the resident's injury and had ordered an x-ray which confirmed the fractures. Staff F indicated that she was made aware the resident had exhibited behaviors during care; however, she could not definitively determine the origin of the injuries. Lastly, Staff F acknowledged that there was no documentation in the resident's record that established the origin of the injuries.Cross reference F-580 and F-609

Based on clinical record review and staff interviews, the facility failed to ensure that all alleged violations including injuries of unknown origin, were reported to the Rhode Island Department of Health (RIDOH) immediately, but not later than 2 hours after the injuries were identified, for 1 of 1 resident reviewed who sustained an injury of unknown origin, Resident ID #1. Findings are as follows:Record review of a community reported complaint submitted to RIDOH on 3/19/2026 alleged that Resident ID #1 sustained an injury of unknown origin and that the resident's family was not notified by the facility at the time of the discovery. The complainant reported that notification was received from the hospice agency.Record review revealed that the resident was admitted to the facility in October of 2025 with a diagnosis including, but not limited to, Alzheimer's disease. The resident was admitted on and continues to receive hospice services (a specialized care for individuals with a terminal illness and are approaching the end of life). Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident is non-ambulatory (a person who is unable to walk) and is dependent on staff for all transfers. Review of a Brief Interview for Mental Status Assessment revealed the resident has severe cognitive impairment.Record review of a progress note authored by Registered Nurse, Staff A, dated 3/9/2026 at 2:40 PM, revealed the resident was grimacing after being brought to the dining room by the staff, and was found to have swelling and bruising to the right ankle. An order was obtained for an x-ray of the right foot and ankle.Record review of an x-ray report dated 3/9/2026 at 11:33 PM confirmed an acute to subacute fractures of the medial malleolus (the inner ankle) with displacement and a moderately displaced fracture of the lateral malleolus (the outer ankle).Record review of a progress note dated 3/10/2026 at 12:15 AM authored by Nurse Practitioner, Staff B, revealed the x-ray results showed an acute to subacute fracture of the medial malleolus and an acute to subacute moderately displaced fracture of the lateral malleolus. Additionally, the progress note revealed an order to contact hospice and the resident's representative to review the findings.Record review failed to reveal evidence that the cause of the injury was identified in the resident's record, which indicates this is an injury of unknown origin. Additional record review failed to reveal evidence that the injury of unknown origin was reported to the Rhode Island Department of Health.During a surveyor interview on 3/24/2026 at 12:24 PM with a hospice aide, Staff C, she stated that she had taken the resident into his/her room after lunch to provide care, accompanied by two of the facility's staff who, Nursing Assistants, Staff D and Staff E. Staff C stated that the resident did not exhibit discomfort prior to care; however, during care, the resident became agitated and flailed his/her upper and lower extremities. She stated that Staff D held down the resident's legs and Staff E held down the resident's arms while care was completed. Staff C acknowledged she did not stop care when the resident became agitated and did not notify the nurse on duty of the resident's behavior. She stated that after care was provided, the resident was transferred to the chair and taken back to the dining room. Staff C stated that she left the unit for her lunch break and upon her return, she learned the resident had a swollen ankle. She stated she did not know how the injury occurred.During a surveyor interview on 3/24/2026 at 1:24 PM, with Registered Nurse, Staff A, she acknowledged that she was the nurse on duty when the resident's injury was identified and was unable to provide evidence that the injury of unknown origin was reported to RIDOH.During surveyor interviews on 3/24/2026 at 12:07 PM and 1:58 PM, with the Director of Nursing Services (DNS), she acknowledged that the facility did not report the injury of unknown origin to RIDOH. Cross reference F-580 and F-610

Based on clinical record review, staff, and resident representative interview, the facility failed to immediately inform the resident's representative of a significant change in condition, which included an injury of unknown origin as the resident was found to have sustained fractures of his/her right ankle for 1 of 2 residents reviewed, Resident ID #1.Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health, on 3/19/2026 alleged that the resident's representative was not informed of an injury the resident sustained and the possible cause.Review of the facility's policy dated 10/19/2023 and titled Notification of Change in Resident's Condition states in part, .responsible family members or legal representatives shall be notified as soon as possible, or within 24 hours, of any changes in the resident's condition. The nurse on duty shall be responsible for notifying the resident's responsible family members when a change occurs.these changes shall include significant changes in physical.as well as any accidents that results in injury. The nurse on duty shall document this notification on the resident's medical record.Record review revealed the resident was admitted to the facility in October of 2025 with a diagnosis including, but not limited to, Alzheimer's disease. The resident was admitted to the facility while receiving and continues to receive hospice services (a specialized care for individuals with a terminal illness who are approaching the end of life). Record review of a progress note authored by Registered Nurse, Staff A dated 3/9/2026 at 2:40 PM, revealed the resident was observed to be grimacing after being brought to the dining room. Further assessment identified the resident's right ankle to be swollen and bruised. An order was obtained for an x-ray of the right ankle and foot.Record review of an x-ray report dated 3/9/2026 at 11:33 PM, confirmed an acute to subacute fractures of the medial malleolus with displacement and a moderately displaced fracture of the lateral malleolus.Record review of a progress note dated 3/10/2026 at 12:15 AM authored by Nurse Practitioner, Staff B revealed the x-ray results showed an acute to subacute fracture of his/her medial malleolus (an inner ankle bone) and a moderately displaced fracture of his/her lateral malleolus (an outer ankle bone). Additionally, the progress note revealed an order to contact hospice and the resident's representative to review the findings.Record review failed to reveal evidence that the resident's representative was notified by the facility of the resident's injuries.During a surveyor interview on 3/24/2026 at 11:20 AM, with the resident's representative, s/he revealed that s/he was not notified by the facility of the resident's injuries. S/he stated that the hospice staff informed him/her of the injuries.During a surveyor interview with Staff A on 3/24/2026 at 1:24 PM, she acknowledged that she was the nurse on duty when the bruising and swelling to the resident's right foot were identified. She further acknowledged that she did not notify the resident's representative of the injuries.During surveyor interviews on 3/24/2026 at 12:07 PM and at 1:58 PM with the Director of Nursing Services, she was unable to provide evidence that the resident's representative was immediately notified of the resident's injuries when they were identified by the staff.Cross reference F-609 and F-610

Based on a review of the clinical record and staff interviews, the facility failed to ensure that services were provided in accordance with professional standards of quality by not following the physician's orders. This failure involved 1 of 1 resident reviewed who was prescribed a medication to prevent an adverse reaction after being served food to which the resident had a known allergy, Resident ID #2.According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.Review of a community reported complaint submitted to the Rhode Island Department of Health on 1/27/2026 alleges that Resident ID #2 experienced an acute medical episode as a result of an allergic reaction.Record review revealed the resident was admitted to the facility in July of 2024 with a diagnosis including, but not limited to, dementia.Review of the resident's listed allergies revealed s/he has an allergy to tomatoes. Further review revealed the tomato sauce allergy was entered into his/her electronic health record on 6/24/2025. Additionally, it revealed the severity of the tomato allergy was unknown.Review of a progress note dated 10/9/2025 at 10:30 AM authored by the Nurse Practitioner states in part, .Patient [Resident ID #2] was also noted to have eaten red tomato sauce in [his/her] food this afternoon which [s/he] has an allergy to.Will recommend Reglan [a medication prescribed to treat heartburn, nausea, and vomiting] 10 mg [milligrams] once.and continued close monitoring for any signs and symptoms of allergic reaction.Review of a physician's order dated 10/9/2025 revealed to administer Reglan 10 mg one time.Review of the October 2025 Medication Administration Record revealed Reglan was coded as 9 by Licensed Practical Nurse, Staff A, indicating to refer to the progress notes.Review of a progress note dated 10/9/2025 at 7:29 PM authored by Staff A revealed that the Reglan was pending delivery from the pharmacy.Record review failed to reveal evidence that the resident received Reglan or that the provider was notified that the resident did not receive his/her medication as ordered.Review of an Inventory Summary dated 1/31/2025 for the facility's Pyxis machine (an automated medication dispensing machine that stocks commonly prescribed medications) revealed that it stocks a minimum of three 5 mg Reglan tablets.During a surveyor interview on 2/5/2026 at approximately 12:30 PM with Staff A, she acknowledged that the Reglan was not administered to the resident as ordered and was unable to provide evidence that the provider was notified.During a surveyor interview on 2/5/2026 at approximately 1:10 PM with the Director of Nursing Services, she revealed that Reglan is regularly stocked in the Pyxis machine and would have expected the resident to have received the medication as ordered. Additionally, she revealed that if a medication is not administered to a resident, she would expect the nurse to notify the provider and document it.Cross reference F 806

Based on clinical record and staff interview, the facility served food to a resident that s/he had a known allergy to, Resident ID #2. Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 1/27/2026 alleges that Resident ID #2 experienced an acute medical episode as a result of an allergic reaction.Record review revealed the resident was admitted to the facility in July of 2024 with a diagnosis including, but not limited to, dementia.Review of the resident's listed allergies revealed s/he has an allergy to tomatoes. Further review revealed the tomato sauce allergy was entered into his/her electronic health record on 6/24/2025. Additionally, it revealed the severity of the tomato allergy was unknown.Review of a progress note authored by the Nurse Practitioner dated 10/9/2025 at 10:30 AM states in part, .Patient [Resident ID #2] was also noted to have eaten red tomato sauce in [his/her] food this afternoon which [s/he] has an allergy to.continued close monitoring for any signs and symptoms of allergic reaction.During a surveyor interview on 2/5/2026 at approximately 1:10 PM with the Director of Nursing Services, she acknowledged that the resident has a documented allergy to tomatoes and should not have been served a tomato product.Cross reference F 658

Based on 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 2 of 3 residents reviewed receiving an antihypertensive (a medication prescribed to lower blood pressure) medication, Resident ID #s 1 and 2. Findings are as follows: 1. Record review revealed Resident ID #1 was admitted to the facility with a diagnosis including, but not limited to, essential hypertension (high blood pressure). Record review revealed a physician's order dated 5/27/2025 for Hydralazine 50 milligrams (mg) three times a day, give if the systolic blood pressure (SBP; refers to the top number of a blood pressure reading and indicates the pressure in your arteries when your heart contracts) is greater than 160. Record review of the May and June 2025 Medication Administration Records (MARs) revealed on the following dates and times the Hydralazine was administered when the SBP was less than 160: -5/27 at 2:00 PM, SBP of 118 -5/27 at 8:00 PM, SBP of 117 -5/28 at 9:00 AM, SBP of 132 -5/28 at 2:00 PM, SBP of 132 -5/28 at 8:00 PM, SBP of 132 -5/29 at 9:00 AM, SBP of 130 -5/29 at 2:00 PM, SBP of 118 -5/29 at 8:00 PM, SBP of 145 -5/30 at 9:00 AM, SBP of 128 -5/30 at 2:00 PM, SBP of 132 -5/30 at 8:00 PM, SBP of 126 -5/31 at 9:00 AM, SBP of 128 -5/31 at 2:00 PM, SBP of 118 -5/31 at 8:00 PM, SBP of 119 -6/1 at 9:00 AM, SBP of 138 -6/1 at 2:00 PM, SBP of 122 -6/1 at 8:00 PM, SBP of 133 -6/2 at 9:00 AM, SBP of 130 -6/2 at 2:00 PM, SBP of 130 -6/2 at 8:00 PM, SBP of 127 -6/3 at 9:00 AM, SBP of 118 -6/3 at 2:00 PM, SBP of 137 -6/3 at 8:00 PM, SBP of 127 During a surveyor interview on 6/5/2025 at 2:32 PM with Licensed Practical Nurse (LPN), Staff A, she acknowledged that Resident ID #1 was administered the Hydralazine medication when the resident's SBP was less than 160, indicating the resident received the medication when s/he should not have. 2. Record review revealed Resident ID #2 was admitted to the facility with a diagnosis including, but not limited to, essential hypertension. Record review revealed a physician's order dated 8/6/2024 for Hydralazine 25 mg every 6 hours, hold for a SBP less than 110. Record review of the May 2025 MAR revealed on the following dates and times the Hydralazine was administered when the SBP was less than 110: -5/7 at 12:00 PM, SBP of 106 -5/14 at 12:00 AM, SBP of 88 -5/14 at 6:00 AM, SBP of 96 -5/16 at 12:00 PM, SBP of 106 -5/17 at 6:00 AM, SBP of 104 -5/23 at 12:00 PM, SBP of 105 -5/25 at 12:00 PM, SBP of 102 During a surveyor interview on 6/5/2025 at 2:55 PM with LPN, Staff B, she acknowledged that Resident ID #2 was administered the Hydralazine when the resident's SBP was less than 110, indicating the resident received the medication when s/he should not have. During a surveyor interview on 6/5/2025 at 3:04 PM with the Director of Nursing Services, she was unable to provide evidence that the Resident ID #s 1 and 2 were free from unnecessary medications.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 3 residents reviewed for medication administration, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 3/12/2025 alleged in part that Resident ID #1 was discharged from a hospital at 11:00 AM and admitted to the facility on [DATE] after undergoing extensive back surgery. Additionally, the facility did not have any of his/her medications available, and s/he was subsequently transferred back to the hospital for pain management later that same day. Review of an undated facility provided document titled, Medication Administration/Ordering Education states in part, .To avoid medications being unavailable it is important for nursing staff to order medications in a timely manner and/or utilize all other avenues of obtaining medication such as the Ekit [Emergency medication kit] and RXNow machine [Pyxis machine; an onsite medication dispensing system that securely stores commonly prescribed medications] .When a medication is due to be administered, and it is not in the cart to administer what should be done .Check all other carts/locations where the medication could have been placed. Other carts, all other drawers, med [medication] room, refrigerator, e-kit, RxNow machine. Call the pharmacy to inquire about the medication that is unavailable .Document conversation with pharmacy in a progress note .The MD/NP [Medical Director/Nurse Practitioner] must be made aware if the medication will not be administered timely. Ask provider for new orders .alternative medication or hold medication until ordered medication is available. Progress note must be written to reflect communication with provider .Please remember that medications are doctors orders and if a medication is not available to give then the MD must be made aware that the medication has not been administered so that an alternative may be ordered if appropriate. 1. Record review revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, fusion of the spine, radiculopathy (a condition caused by a pinched nerve in your spine), type II diabetes, high blood pressure, gastro-esophageal reflux disease (GERD), and hyperlipidemia (high fat levels in the blood). a) Additional record review revealed the following physician's orders: - 1/31/2025 Atorvastatin, give 10 milligrams (mg) at 4:00 PM for hyperlipidemia - 1/31/2025 Calcium Carbonate, give 1200 mg at 7:00 AM and 4:00 PM for supplement - 1/31/2025 Carvedilol, give 12.5 mg at 7:00 AM and 4:00 PM for high blood pressure - 1/31/2025 Polyethylene Glycol powder, give 17 grams at 7:00 AM and 4:00 PM for constipation - 1/31/2025 Metformin, give 1000 mg at 7:00 AM and 4:00 PM for diabetes type II - 1/31/2025 Senna-Docusate Sodium, give 17.2-100 mg at 7:00 AM and 4:00 PM for constipation Review of a progress note dated 1/31/2025 at 10:20 PM revealed that the resident was admitted to the facility with his/her family member present (earlier in the day). Additionally, the resident presented with pain upon arrival, was treated with several doses of pain relief medication, and was subsequently transferred back to the hospital for pain management (in the late evening) on the same day. Record review revealed that s/he returned to the facility on [DATE]. Review of the January 2025 Medication Administration Record (MAR) failed to reveal evidence that the resident received his/her Atorvastatin, calcium carbonate, carvedilol, polyethylene glycol, Metformin, or senna-docusate sodium medication on 1/31/2025 at 4:00 PM, when the resident was still present at the facility. During a surveyor interview on 3/13/2025 at 11:38 AM with Registered Nurse, Staff A, she revealed that if a medication for a resident is unavailable or has yet to be delivered by the pharmacy, she will check the Pyxis machine to see if the medication is available. Additionally, she would notify the provider if a resident missed a medication administration and document it in his/her progress notes. Record review failed to reveal evidence that the provider was notified of the above-mentioned missed medication administrations. During a surveyor interview on 3/13/2025 at 12:30 PM with a Registered Pharmacist, he revealed that Atorvastatin, Carvedilol, and Metformin are all available in the Pyxis machine. Additionally, he revealed that calcium carbonate, polyethylene glycol, and senna-docusate sodium are over the counter medications and are available as facility stock. b) Review of a physician's order dated 2/5/2025 revealed to inject Mounjaro 2.5 mg every Wednesday at 7:00 AM for diabetes type II. Review of the February 2025 MAR revealed that Mounjaro was documented as 9 by Licensed Practical Nurse, Staff C, indicating Other / See Progress Notes. Review of a progress note dated 2/5/2025 at 9:48 AM authored by Staff C, revealed that the Mounjaro was not available. Record review failed to reveal evidence that the pharmacy was contacted or that the provider was notified that the resident's Mounjaro was unavailable to be administered. During a surveyor interview on 3/13/2025 at 12:45 PM with Staff C, she acknowledged that the Mounjaro was unavailable to be administered and that she did not notify the resident's provider, and she should have. During a surveyor interview on 3/13/2025 at approximately 1:00 PM with the Regional Director of Nursing Services, she revealed that she would expect the resident to have received the above-mentioned medications as ordered and would expect that staff would have contacted the provider and documented in the progress notes if the resident did not receive his/her medication. During a surveyor interview on 3/13/2025 at 1:54 PM with the Nurse Practitioner, she revealed that she would expect staff to follow provider's orders and to notify her if a resident does not receive his/her medications. Cross reference F 697 and 842

Based on record review and staff interview, it has been determined that the facility failed to accurately maintain the resident's medical record in accordance with accepted professional standards and practices for 1 of 1 newly admitted resident reviewed, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 3/12/2025 alleged in part that Resident ID #1 was discharged from a hospital at 11:00 AM and admitted to the facility on [DATE] after undergoing extensive back surgery. Additionally, the facility did not have any of his/her medications available, and s/he was subsequently transferred back to the hospital for pain management later that same day. Further, the resident's neurosurgeon had ordered Decadron (a steroid medication prescribed to treat inflammation), however the nursing facility was unaware s/he was prescribed it. Record review revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, fusion of the spine and radiculopathy (a condition caused by a pinched nerve in your spine). Review of a hospital document titled, Continuity of Care [COC] - Post-Acute Facility dated 1/31/2025 revealed that the resident underwent spinal surgery and was to start taking oxycodone (an opioid medication prescribed to treat moderate to severe pain) one to two tablets every four hours as needed for pain (5 to 10 milligrams [mg]). Review of a physician's order dated 1/31/2025 revealed to administer oxycodone, one tablet (5 mg), every 4 hours as needed for pain. Additionally, record review failed to reveal evidence of an order for oxycodone, two tablets (10 mg), for pain, as indicated in the hospital COC form, or that the order for multiple tablets was addressed with the provider. Further review of the hospital COC form revealed that the resident was receiving Decadron 2 mg every 8 hours in the hospital and had an end date of 1/31/2025 at 9:59 PM. Additionally, it indicated that s/he was to receive another dose on 1/31/2025 at 2:00 PM according to page 11 of the document. Record review failed to reveal evidence that the resident received the Decadron at 2:00 PM, that the medication was transcribed to be administered as indicated in the hospital COC form, or that the medication was addressed with the provider. During a surveyor interview on 3/13/2025 at approximately 1:00 PM with the Regional Director of Nursing Services, she revealed that she would expect that staff would have addressed the Decadron medication and oxycodone order with the resident's provider and document the interaction in a progress note. Additionally, she was unable to provide evidence that the facility maintained medical records that are accurate. Cross reference F 697 and 760

Based on record review and staff interview, it has been determined that the facility failed to ensure that adequate pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 residents reviewed for pain, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 3/12/2025 alleged in part that Resident ID #1 was discharged from a hospital at 11:00 AM and admitted to the facility on [DATE] after undergoing extensive back surgery. Additionally, the facility did not have any of his/her medications available, and s/he was subsequently transferred back to the hospital for pain management later that same day. Further, his/her neurosurgeon had ordered Decadron (a steroid medication prescribed to treat inflammation), however the nursing facility was unaware s/he was prescribed it. 1. Record review revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, fusion of the spine and radiculopathy (a condition caused by a pinched nerve in your spine). Review of a care plan focus area dated 1/31/2025 revealed the resident has pain with a goal for the resident to verbalize adequate pain relief or the ability to cope with incompletely relieved pain. a. Review of a hospital document titled, Continuity of Care [COC] - Post-Acute Facility dated 1/31/2025 revealed that the resident underwent spinal surgery and was to start taking oxycodone (an opioid medication proscribed to treat moderate to severe pain) one to two tablets every four hours as needed for pain (5 to 10 milligrams [mg]). Additionally, it indicated that his/her pain was well controlled with oral pain medications. Review of a physician's order dated 1/31/2025 revealed to administer oxycodone, one tablet (5 mg), every 4 hours as needed for pain. Additionally, record review failed to reveal evidence of an order for oxycodone, two tablets (10 mg), for pain, as indicated on the hospital COC form. Review of a progress note dated 1/31/2025 at 10:20 PM revealed that the resident was admitted to the facility with his/her family member present (earlier in the day). Additionally, the resident presented with pain upon arrival, his/her pain was escalating after receiving 2 separate administrations of oxycodone 5 mg, and the provider gave a new order to administer oxycodone 10 mg for severe pain. S/he was subsequently transferred back to the hospital for pain management for 10 out of 10 pain (in the late evening). Review of the January 2025 Medication Administration Record (MAR) revealed that the resident received only 5 mg of oxycodone on 1/31 at the following times: - 1:00 PM for 8 out of 10 pain - 5:36 PM for 9 out of 10 pain During a surveyor interview on 3/13/2025 at 1:11 PM with Registered Nurse, Staff A, she revealed that when reviewing the hospital COC form upon admission, if there are orders to administer one to two tablets of a pain medication, she will verify that with the provider and document it. She further revealed that if a resident is admitted with an oxycodone order indicating to administer one to two tablets, the provider typically orders to administer one tablet for mild to moderate pain, and to administer two tablets for severe pain. b. Additional review of a hospital document titled, Continuity of Care - Post-Acute Facility dated 1/31/2025 revealed that the resident was receiving Decadron 2 mg every 8 hours in the hospital and had an end date of 1/31/2025 at 9:59 PM. Additionally, it indicated that s/he was to receive another dose on 1/31/2025 at 2:00 PM according to page 11 of the document. Record review failed to reveal evidence that the resident received the Decadron at 2:00 PM, that the medication had been transcribed to be administered as indicated in the hospital COC form, or that the medication was addressed with the provider. During a surveyor interview on 3/13/2025 at 12:37 PM with Licensed Practical Nurse, Staff B, she revealed that she reviews the entire hospital COC form and will reference all pages to ensure accuracy and timely administrations of medications, and verifies all orders with the resident's provider. During a surveyor interview on 3/13/2025 at approximately 1:00 PM with the Regional Director of Nursing Services, she acknowledged that the Decadron order was not listed in one section of the COC document, but was listed on page 11 of the document. Additionally, she revealed she would expect that the staff nurse would have addressed the Decadron order with the resident's provider and document the interaction in a progress note. During a surveyor interview on 3/13/2025 at 1:54 PM with the Nurse Practitioner, she revealed that she was the provider who verified the resident's medications upon admission and does not recall staff addressing the Decadron medication. Additionally, she revealed that for oxycodone 1-2 tablet orders, she typically will order one tablet for mild/moderate pain and two tablets for severe pain. Further, she acknowledged that if the resident had received the two tablets of oxycodone initially for his/her severe pain, his/her pain may have been better controlled and s/he may not have required transport to the hospital for pain management. Cross reference F 760 and F 842

Based on record review and staff interview, it has been determined that the facility failed to provide care consistent with professional standards of practice for 1 of 2 residents reviewed with an ostomy (colostomy/ileostomy; a surgical procedure that creates an opening (stoma) in the abdomen to divert waste products from the body to an external pouch), Resident ID #1. Findings are as follows: Record review of a community reported complaint allegation submitted to the Rhode Island Department of Health on 1/26/2025 alleges that the facility did not have appropriate ostomy bag or staff trained to care for a resident in need of ostomy care. Review of a facility policy titled, Colostomy and Ileostomy Care last revised on 11/13/2024, states in part, .Applying or changing the pouch .Inspect the color and skin integrity of the stoma and peristomal skin .If applying a two-piece appliance with a separate skin barrier, peel off the paper backing of the prepared skin barrier, center the barrier over the stoma, and press gently to ensure adhesion .Document .type and size of appliance used .Appearance of the stoma and peristomal skin .Notification of physician .if applicable .patients response . Record review revealed that Resident ID #1 was admitted to the facility in January of 2025 with a diagnosis including, but not limited to, ileostomy status. Additional record review revealed that s/he has an ileostomy to his/her right lower abdomen. Furthermore, the record revealed a mid-abdominal wound and a group of surgical wounds to his/her left lower abdomen. Record review revealed a progress note dated 1/26/2025 at 11:18 AM that revealed the resident's family member was requesting the resident to be transferred to the hospital due to concerns that he/she was not receiving appropriate care for the ostomy and the wounds. Record review of a hospital document dated 1/26/2025 revealed that Resident ID #1 was transferred to the emergency room [ER] and was experiencing pain around the ostomy. Additionally, it revealed that the ostomy appliance(wafer) was not adhered to his/her skin and stool was leaking into a mid-abdominal incision (surgical wound). It further revealed that the facility did not have the correct ileostomy supplies. Further record review failed to reveal evidence of the size and type of ostomy supplies to be used for the resident. During a surveyor interview on 1/27/2025 at 12:50 PM with Licensed Practical Nurse (LPN), Staff A, she acknowledged that the wafer did not adhere to the resident's skin, and she needed to cut the wafer because the appliance that the facility had on hand was not the appropriate size. She also indicated that the peristomal skin appeared to have some redness from the leakage of stool as the appliance did not fit properly. During a surveyor interview on 1/27/2025 at 2:04 PM with Registered Nurse, Staff B, she revealed that she assessed the residents' abdominal wounds on 1/26/2025 and that there was redness to the peristomal area. Additionally, she revealed that the ostomy wafer did not adhere to the resident's abdomen. During a surveyor interview on 1/28/2025 at 11:08 AM, with the Wound Nurse, Staff C she revealed that she changed the resident's wafer (a device which is fitted or cut to the individual size of the stoma) on 1/24/2025 after being informed by a family member that it was leaking. The wound nurse acknowledged that the wafer did not adhere to his/her skin properly. She further revealed that she ordered a smaller size wafer that was to arrive the next day. She revealed that after she had changed the wafer on 1/24/2025 it held on for a few more hours and was then change again by another nurse because it was leaking. During a surveyor interview on 1/28/2025 at approximately 11:30 AM with the Director of Nursing Services, she acknowledged that the resident did not receive the appropriate size ostomy supplies to prevent fecal leakage into the abdominal wound.

Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional standards for 2 of 3 medication storage rooms observed. Findings are as follows: Record review of a facility policy titled Medication Storage, last revised on 2/4/2022 states in part, .Medications and biologicals labeled in accordance with currently accepted professional principles, and include: -Appropriate accessory and cautionary instructions . -Expiration date, when applicable . Multi-dose vials which have been opened or accessed (e.g. needle punctured) should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. During a surveyor observation of the North Medication Storage Room on 12/18/2024 at 10:30 AM, in the presence of Licensed Practical Nurse (LPN), Staff E, 1 vial of Tuberculin Purified Protein Derivative (tuberculin skin test solution) opened and not dated. Staff E acknowledged that the vial should have been dated when opened. Additionally, the manufacturer instructions indicated to discard the vial after 30 days of opening. During a surveyor observation of the East Medication Storage Room on 12/18/2024 at 11:24 AM, in the presence of LPN, Staff F, one bottle of Ativan Intensol (medication for anxiety) was observed opened and not dated. Staff F acknowledged the vial should have been dated when opened. Additionally, the instructions on the bottle indicated to discard after 90 days of opening. During a surveyor interview with the Director of Nursing Services on 12/18/2024 at 2:13 PM, she revealed that she would expect that the medication bottles be dated once opened, and that both the Ativan Intensol and Tuberculin should be discarded.

Based on record review and staff interview, it has been determined that the facility failed to maintain medical records that are complete and accurately documented on each resident, in accordance with accepted professional standards and practices, for 1 of 4 residents reviewed related to urinary catheter (a flexible tube inserted into the bladder to drain urine), and for 1 of 3 residents reviewed related to advance directives, Resident ID #105. Findings are as follows: Record review revealed the resident was admitted to the facility in December of 2023 with a diagnosis including, but not limited to, urinary retention. 1. Record review of the resident's physician order list revealed the following conflicting orders related to the size of catheter being utilized for the resident: - Change the resident's foley catheter monthly and as needed with 16 Fr (French sizing system - measurement of the urinary catheter based on its outer diameter) with 10 mL (milliliter) balloon as needed with a start date of [DATE]. - Change the resident's foley catheter monthly and as needed with 16 Fr, 10 mL balloon every day shift every 30 days for catheter care with a start date of [DATE]. - Change the resident's foley catheter monthly and as needed with 18 Fr, 5 mL balloon for urinary retention every day shift every 30 days with a start date of [DATE]. - Change the resident's foley catheter monthly and as needed with 18 Fr, 5 mL balloon with a start date of [DATE]. During a surveyor interview on [DATE] at 10:28 AM with Licensed Practical Nurse (LPN), Staff G, in the presence of the Regional Director of Sales and Marketing, LPN Staff H, she revealed that the resident's current catheter size is 18 Fr. Further surveyor interview on [DATE] at 11:20 AM with Staff H, he revealed that the resident's physician order for 16 Fr should have been discontinued, and his/her most recent physician order is for an 18 Fr. 2. Record review of the resident's advanced directives revealed that s/he is a Do Not Resuscitate (a medical order that instructs health care providers not to perform cardiopulmonary resuscitation (CPR) if a patient's heart stops or breathing stops) and No Artificial Nutrition (a medical order to stop or not start providing artificial nutrition and hydration (ANH) to a patient). Review of the resident's record revealed that another resident's advance directives were uploaded on his/her miscellaneous documents on [DATE] which indicates a Full Code Status (the healthcare team will perform all possible resuscitation procedures to try and save their life, including CPR, defibrillation, and other life-saving measures) and to Administer Artificial Nutrition Via Feeding Tube. During a surveyor interview on [DATE] at 10:28 AM with Staff H, he asked Staff G to delete the other resident's advance directive uploaded in Resident ID #105's record. During a surveyor interview on [DATE] at 12:17 PM with the Director of Nursing Services, she acknowledged there were multiple orders for the resident's foley catheter size that did not match. Additionally, she was unable to provide evidence that the resident's medical record was maintained accurately related to his/her advance directives. 45855

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 3 residents reviewed related to calling for assistance for pain, Resident ID #75. Findings are as follows: Record review of the policy titled Call Bell Policy revealed that the staff should ensure the resident is safe and the call bell is within reach. Record review of the Minimum Data Set assessment dated [DATE] revealed a Brief interview for Mental Status score of 15 of 15, indicating intact cognition. During a surveyor observation on 12/17/2024 from 12:28 PM through 12:50 PM, the resident was noted to be yelling out for help asking for assistance related to his/her pain for the past half hour. During a surveyor interview on 12/17/2024 at 12:55 PM with Nursing Assistant, Staff C, she acknowledged that the resident's call bell was on the ground and failed to be within reach of the resident. During a surveyor interview on 12/17/2024 at 1:01 PM with the resident, s/he revealed that his/her call bell fell on the floor and has been yelling for help. During a surveyor interview on 12/17/2024 at 1:38 PM with the Director of Nursing Services, she revealed that she would expect the resident's call bell to be placed within the resident's reach.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide appropriate treatment and services to 1 of 2 residents reviewed with a Suprapubic Catheter (SPC) (a flexible plastic tube inserted into your bladder via a surgical opening in the abdomen), Resident ID #67. Findings are as follows: Record review revealed that the resident was admitted to the facility with a diagnosis including, but not limited to, obstructive and reflux uropathy (condition in which urine flows backward from the bladder to one or both kidneys). Record review of the textbook, Lippincott Nursing Procedures, 9th Edition, pages 432-33 states in part, Catheter care .Keep the drainage bag below the level of the patient's bladder to prevent backflow of urine into the bladder, which increases the risk of CAUTI [A catheter-associated urinary tract infection caused by germs entering the urinary tract through a catheter]. Record review revealed a physician's order dated 7/27/2024 for catheter care to be provided every shift and as needed relative to the SPC tube. Record review of a care plan dated 7/27/2024 revealed a focus of potential for infection related to SPC with an intervention to maintain the catheter bag below bladder level. During surveyor observations on 12/17/2024 at 8:43 AM and 9:37 AM, revealed the resident was lying in bed with the catheter bag lying flat on the mattress next to him/her. During a surveyor interview at 9:37 AM immediately following the above observation with the resident, s/he stated that s/he doesn't know who put the catheter bag on the mattress. Additional surveyor observations on 12/17/2024 at 9:57 AM and 10:12 AM revealed Nursing Assistants, Staff C and D, entering the resident's room and failing to move the catheter bag below bladder level per the resident's care plan. During a surveyor interview at 10:12 AM, immediately after the above observation, with Licensed Practical Nurse (LPN), Staff A, he acknowledged that the catheter bag should have been placed lower than the resident's bladder level. Further surveyor observations on 12/18/2024 at 8:45 AM and 8:52 AM, revealed the catheter bag was lying flat on top of the mattress, next to the resident. During a surveyor interview on 12/18/2024 at 8:52 AM, immediately following the above observation, the Assistant Director of Nursing Services, acknowledged that the catheter bag was lying on top of the mattress next to the resident. Additionally, she revealed that she would expect staff to maintain the catheter bag below the resident's bladder level, per his/her plan of care.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain professional standards of practice relative to a peripherally inserted central catheter (PICC - a type of vascular access device [VAD] used to deliver medications directly to the large central veins near the heart) to 1 of 1 resident observed for intravenous (IV) antibiotic administration via a PICC line, Resident ID #321, and 1 of 3 residents reviewed who receive medication in crushed form, Resident ID #77. Findings are as follows: 1) Review of a facility policy titled, SETTING UP A PRIMARY INFUSION (HYDRATION or MEDICATION) dated 8/2021 states in part, .Attach flush syringe, aspirate for a blood return to determine patency and then flush resident's IV catheter with appropriate flush solution as ordered .Scrub needleless connector on resident's catheter with antiseptic wipe .Attach primed IV tubing to the needleless connector . Record review revealed Resident ID #321 was admitted to the facility in December of 2024 with a diagnosis including, but not limited to, bacteremia (bacteria in the blood). Review of a care plan that was initiated on 12/5/2024, revealed that the resident has a PICC line to his/her right arm and receives IV antibiotics for bacteremia. Record review revealed a physician's order dated 12/4/2024 for ampicillin (antibiotic) 2 grams to be given intravenously every 4 hours for a bacterial infection. During a surveyor observation on 12/17/2024 at 12:06 PM of Licensed Practical Nurse, Staff A, he failed to assess for blood return prior to administering the ampicillin intravenously. Additionally, Staff A disconnected the IV tubing due to the infusion pump alarming, and failed to scrub the needleless connector on the resident's catheter prior to reconnecting the IV tubing. During a surveyor interview immediately following the above observation with Staff A, he acknowledged that he failed to assess for blood return prior to administering the ampicillin to the resident, and failed to scrub the needleless connector prior to reconnecting the IV tubing. During a surveyor interview with the Director of Nursing Services on 12/17/2024 at 12:30 PM, she acknowledged that she would expect staff to assess the patency of the PICC line by flushing and assessing for blood return prior to infusing IV medication, and scrub the connector prior to connecting the IV tubing. 2) Record review revealed Resident ID #77 was admitted to the facility in March of 2021 with a diagnosis including, but not limited to, dysphagia (difficulty swallowing). Record review of the face sheet and the care plan revealed special instructions to crush medications. Record review revealed a physician's order with a start date of 9/5/2024 for Seroquel (a medication used to treat mental health disorders) 50 milligrams (mg) tablet and a 25 mg tablet, to be given together, for a total dose of 75 mg twice daily. During a surveyor observation on 12/18/2024 at 11:39 AM of Certified Medication Technician, Staff B, she administered both tablets of Seroquel to the resident whole with cranberry juice, not in crushed form, as indicated in the special instructions. During a surveyor interview immediately following the above observation with Staff B, she acknowledged that she failed to crush the resident's Seroquel per the special instructions. During a surveyor interview with the Director of Nursing Services on 12/18/2024 at 2:13 PM, she revealed that she would expect the staff to have crushed the resident's Seroquel tablets prior to administering them.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to following physician orders for obtaining weights for 2 of 3 residents reviewed, Resident ID #s 1 and 2. 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 physicians' orders unless they believe the orders are in error or would harm the clients. 1. Record review revealed Resident ID #1 was admitted to the facility in December of 2024 with diagnoses including, but not limited to, atherosclerotic heart disease (artery is narrowed or clogged and it is unable to bring enough blood to organs and tissues) with unstable angina pectoris (chest pain), and congestive heart failure. Record review of a care plan dated 12/4/2024 revealed the resident is at risk for complications related to congestive heart failure with interventions including, but not limited to, weight monitoring as ordered. Record review of a physician's order dated 12/4/2024 revealed an order for daily weights to be obtained every day shift for monitoring. The order also included instructions to notify the Physician (MD) or Nurse Practitioner (NP) of a weight gain of 3 pounds (lbs.) in one day or 5 lbs. in one week. Record review of the December 2024 Medication Administration Record (MAR) revealed the daily weights were not obtained on the following dates: -12/5/2024 -12/6/2024 -12/9/2024 Review of the progress notes failed to reveal evidence that the above weights were obtained or that the MD or NP were notified that they were not obtained. 2. Record review revealed Resident ID #2 was admitted to the facility in November of 2024 with diagnoses including, but not limited to, congestive heart failure, and supraventricular tachycardia (an irregular fast heartbeat). Record review of a care plan dated 11/23/2024 revealed the resident is at risk for complications related to congestive heart failure with interventions including, but not limited to, weight monitoring as directed. Record review of a physician's order dated 11/25/2024 revealed an order for daily weights to be obtained every day shift for monitoring. The order also included instructions to notify the MD or NP of a weight gain of 3 lbs. in 1 day or 5 lbs. in one week. Record review of the November and December MARs revealed the daily weights were not obtained on the following dates: 11/26/2024 11/27/2024 11/28/2024 11/29/2024 11/30/2024 12/1/2024 12/2/2024 12/3/2024 12/4/2024 12/5/2024 12/7/2024 12/9/2024 Review of the progress notes failed to reveal evidence that the above weights were obtained or that the MD or NP were notified that they were not obtained. During a surveyor interview on 12/10/2024 at approximately 1:15 PM with Licensed Practical Nurse (LPN), Staff A , she acknowledged that she documented that the weights were unable to be obtained on several of the dates above. She revealed that recently the nursing assistants have not been getting the weights. She further revealed that she did not report to the MD or NP that they were unable to obtain the resident's weights, because she was unaware that she was supposed to. During a surveyor interview on 12/10/2024 at approximately 1:54 PM with LPN, Staff B, he acknowledged that he documented that weights were unable to be obtained on some of the dates above. Additionally, he stated that if he notified the MD or NP that the weights were not obtained, he would have noted it in his progress notes. During a surveyor interview on 12/10/2024 at approximately 2:00 PM with NP, Staff C , she revealed that orders for daily weights are usually put in place for cardiac reasons. Additionally, she revealed that she was not notified the daily weights for the above residents were not being obtained. During a surveyor interview on 12/10/2024 at approximately 2:30 PM with the Director of Nursing Services, she revealed that she would expect the daily weights to be obtained per the physician's order. She further revealed that she would expect the next shift to try and obtain the weights if the day shift was unable to obtain them. Additionally, she would expect the nurse to report it to the MD or NP if the weights were unable to be obtained.

Based on record review and staff interview, it has been determined that the facility failed to obtain complete admission orders for the resident's immediate care for 1 of 1 resident reviewed who was not administered the prescribed medications after being readmitted to the nursing facility from the hospital, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health on 10/29/2024 alleges that the resident was not administered the prescribed amiodarone (a medication that treats a fast or irregular heart rhythm by reducing symptoms and helps avoid life-threatening complications) on his/her readmission to the facility from the hospital on 10/11/2024. Additionally, the allegation indicates that the failure resulted in his/her return to the hospital. Record review revealed that Resident ID #1 was initially admitted to the facility on [DATE] with diagnoses including, but not limited to, congestive heart failure (CHF, a condition that happens when a person's heart can't pump blood well enough to give the body a normal supply. Blood and fluids collect in the lungs and legs over time) and persistent atrial fibrillation (A-fib, a serious fast and irregular heart rhythm that requires medical intervention. If left untreated, a person is placed at risk of developing blood clots that can lead to heart attack or stroke). Further record review revealed that the resident transferred from the facility to the hospital on 9/28/2024 and subsequently transferred to a different hospital for further management of difficulty breathing and an irregular heart rhythm. S/he was readmitted to the facility on [DATE]. Record review revealed that 22 files containing hospital documents, labeled Admission Documents were scanned into the resident's electronic medical record on 10/11/2024. Additional record review revealed that one of the 22 files contained a 7-pages long document dated 10/9/2024 titled, Patient Information. Page 2 of this document revealed a section titled, Patient's Medications Prior To Admission. Further record review failed to reveal evidence of a hospital continuity of care form or discharge summary which would include the medication's Resident ID #1 should receive upon readmission to the facility. Additionally, the record failed to reveal evidence of a physician's order for amiodarone dated 10/11/2024. During a surveyor interview on 10/29/2024 at 2:16 PM, with Registered Nurse, Staff A, she revealed that she was Resident ID #1's Unit Manager. Additionally, she was unable to provide evidence of a hospital discharge summary or continuity of care form that included medications the resident was to receive upon readmission to the facility on [DATE]. Additionally, she acknowledged that the 7-page document revealed a list of medications the resident was on prior to admission to the hospital and did not indicate what s/he was to receive after readmission to the facility. During a surveyor interview on 10/29/2024 at 2:19 PM, with the Director of Nursing Services (DNS), she revealed that Resident ID #1's medication orders upon readmission to the facility on [DATE] were transcribed from the document titled Patient's Medications Prior To Admission. She indicated that those were the documents the admitting nurse received from the hospital upon the resident's readmission. She indicated that she was made aware of the missed medications concerns after the resident was sent back to the hospital on 10/26/2024. At this time the facility obtained the DISCHARGE SUMMARY form from the 10/11/2024 hospital discharge which included the medications the resident was prescribed to take. A telephone interview was attempted with the admitting nurse, Licensed Practical Nurse, Staff B on 10/30/2024 at 9:35 AM, however she was unable to be reached. A voicemail was left, and a return telephone call has not been received. Further record review of the hospital document dated 10/11/2024 titled, DISCHARGE SUMMARY revealed that Resident ID #1 should start taking the following medications on 10/11/2024: - amiodarone 400 milligrams (mg) one tablet by mouth three times a day for 2 days, then one tablet once daily for 90 days until s/he follows up with his/her heart specialist. - Anora Ellipta (inhaler medication used to help improve difficulty with breathing) 62.5-25 micrograms, one puff by mouth once daily. - furosemide (water pill, used to treat patients diagnosed with heart failure by removing excessive water from the body) 20 mg once daily. Further record review failed to reveal evidence of physician's orders for the amiodarone, Anora Ellipta, or furosemide dated 10/11/2024 which indicates s/he was not administered the above medications for a total of 16 days. Additional record review revealed that Resident ID #1 was transferred back to the hospital on 10/26/2024 due to complaints of difficulty breathing. Review of the hospital Emergency Department (ED) document dated 10/26/2024 revealed that his/her treatment plan includes admission for management of conditions including, but not limited to, A-fib with rapid ventricular rate (a type of irregular heart rhythm, when the heart doesn't have a normal signaling process telling the heart when to beat) CHF and possible aspiration pneumonia. Additionally, the document indicates that the hospital contacted the nursing facility concerning the missed discharge orders from 10/11/2024. During a surveyor interview with Resident ID #1's physician on 10/30/2024 at 11:30 AM, he indicated that he would expect that the nurse would have contacted the hospital and request the correct continuity of care form and follow the instructions. During a surveyor interview on 10/31/2024 at 10:51 AM, with the DNS, she stated that the admitting nurse transcribed the orders from the document she received upon the resident's admission and acknowledged that the documents were not the discharge orders. Additionally, she stated that she would have expected that the nurse would have requested the correct discharge documents. She also acknowledged that the resident missed 16 days of his/her Anora Ellipta and furosemide.

Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to provide a safe and sanitary environment to help prevent the transmission of infections relative to disinfecting glucometers (a device used to monitor blood glucose) for 3 of 4 residents observed who require blood glucose monitoring, Resident ID #s 43, 317 and 108. Findings are as follows: 1. According to the facility's policy last revised in March of 2015 titled, diabetes-care of equipment states in part, .5. If a glucometer is to be used for one resident and then reused for another, the device must be cleaned and disinfected between uses. Directions vary between manufacturers and even between models within brands. Follow the glucometer manufacturer's recommendations for cleaning . Review of the glucometer manufacturer's User Instruction Manual Reference titled, Assure Prism Multi Blood Glucose Monitoring System, states in part, .Cleaning and Disinfecting: The disinfection procedure is needed to prevent transmission of blood-borne pathogens. The meter should be cleaned and disinfected after use on each patient. This Blood Glucose Monitoring System may only be used for testing multiple patients when Standard Precautions and the manufacturer's disinfection procedures are followed. We have validated Clorox Healthcare Bleach Germicidal Wipes, dispatch Hospital Cleaner Disinfectant Towels with Bleach, Cavi Wipes1 and PDI Super Sani-Cloth Germicidal Disposable wipe for disinfecting the Assure Prism multi meter .Only wipes with Environmental Protection Agency [EPA] registration numbers listed in the previous tables have been validated for use in cleaning and disinfecting the meter. Any disinfectant product containing these EPA registration numbers may be used on this device . a) Record review revealed Resident ID #43 was readmitted to the facility in December of 2023 with diagnoses including, but not limited to, type II diabetes. Additionally, review of the Medication Administration Record (MAR) revealed the resident's blood sugars are documented as monitored daily at the following times: 6:30 AM, 8:00 AM, 4:30 PM and at bedtime. b) Record review revealed Resident ID #317 was admitted to the facility in January of 2024 with a diagnosis including, but not limited to, type II diabetes. Additionally, review of the MAR revealed the resident's blood sugars are documented as monitored daily at the following times: 7:30 AM, 8:00 AM, 11:30 AM and 4:30 PM. c) Record review revealed Resident ID #108 was admitted to the facility in December of 2023 with diagnoses including, but not limited to, type 2 diabetes mellitus, unspecified viral Hepatitis B (a virus that is passed from person to person through blood), and Syphilis (an infection caused by bacteria that is most often sexually transmitted). Additionally, review of the MAR revealed the resident's blood sugars are documented as monitored daily at the following times: 6:30 AM, 7:30 AM, 9:00 AM, 11:30 AM, 1:30 PM and 4:30 PM. During surveyor observations on 1/18/2024 during the medication administration task with Licensed Practical Nurse (LPN), Staff D, the following observations were made: - 10:46 AM, Staff D cleansed the Assure Prism multi glucometer with an alcohol prep pad then obtained Resident ID #43's blood sugar. Staff D then used an alcohol prep pad to clean the glucometer. Staff D did not utilize a validated disinfectant wipe to disinfect the glucometer as per the manufacturer's guidelines, prior to placing the glucometer into a basket containing clean blood glucose supplies and returning it to the cart. - 11:35 AM ,Staff D obtained Resident ID #317's blood sugar with the same glucometer used for Resident ID #43. Staff D again cleansed the Assure Prism Multi glucometer with an alcohol prep pad prior to entering the room. This surveyor stopped Staff D when she indicated that she was ready to obtain the resident's blood sugar and asked to speak with her for a minute in the hallway. During a surveyor interview, immediately following the above observation, Staff D stated that she always uses Alcohol prep pads to cleanse the glucometer. She further indicated that she was unaware that this was an improper disinfection practice. Staff D was asked about the manufacturer's instruction manual, she then returned with the appropriate disinfectant wipes, and obtained the blood sugar. During a surveyor observation on 1/18/2024 with LPN, Staff E, the following was revealed: 12:14 PM, Staff E entered Resident ID #108's room and obtained his/her blood sugar with an Assure Prism Multi glucometer. After obtaining the blood sugar, Staff E wiped the glucometer with an alcohol prep pad, exited the resident's room and placed the glucometer in a plastic basket on the nurse's cart containing clean blood glucose supplies. During a surveyor interview with Staff E immediately following the above observation he acknowledged that he wiped the glucometer with an alcohol prep pad after obtaining the residents blood sugar. He further revealed that using an alcohol prep pad to disinfect the glucometer after use was his common practice. During a subsequent interview on 1/18/2024 at 1:43 PM with Staff E he indicated that the glucometer used in the above observation is used for multiple residents on the unit. Additionally, he indicated that he did not have the appropriate sanitizing wipes in the nurse's cart he was using. During a surveyor interview on 1/18/2024 at 4:19 PM with the Director of Nursing Services (DNS), in the presence of an additional surveyor, she revealed that she would expect that the manufacturer's instructions would be followed for disinfecting the glucometer. As a result of the facility's failure to follow its own diabetes-care of equipment policy relative to glucometers, and more specifically, the glucometer's reference manual specific to the cleaning and disinfection process, placed all residents who require blood glucose monitoring at an increased risk for the transmission of blood borne pathogens. 46118

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 devices to prevent accidents for 1 of 3 residents reviewed for falls, Resident ID #7. Findings are as follows: Record review of a facility policy and procedure document titled Falls Reduction Program states in part, .establish a care plan that identifies risk factors exhibited by the resident and which directs employees regarding measures to be taken to mitigate or eliminate those risk factors .The at-Risk Committee is responsible to review the resident record, perform in-depth analysis of each event .to assure that .interventions are in place to reduce risk of future falls .9. Evaluate .interventions already put into place to reduce each resident's risk of falls .Develop action plans for facility interventions related to risk reduction . Record review of a facility reported incident submitted to the Rhode Island Department of Health on 1/30/2023 states in part, Patient sustained unwitnessed fall .sent to hospital .admitted to [hospital] . Review of hospital documentation dated 1/29/2023 states in part, .SNF [Skilled Nursing Facility] found this morning, trying to get to bathroom w/o [without] walker, tripped and fall .Patient states that [s/he] tripped on [his/her] way to the bathroom and was unable to get up .Patient also with 2 parietal occipital [back of the head] scalp hematomas [abnormal collection of blood outside of a blood vessel due to disease or trauma] .left-sided fifth or seventh rib fractures, ninth and 10th rib fractures, and a questionable eighth rib fracture. Humerus [bone of upper arm] fracture confirmed .Reportedly, often ambulates to bathroom without [his/her] walker . Record review revealed the resident was admitted to the facility in March of 2022 with diagnoses including, but are not limited to, metabolic encephalopathy (disturbed brain function from diseases or toxins in the body), chronic obstructive pulmonary disease (lung disease), difficulty in walking, and dementia. Review of a facility assessment titled, MORSE FALL SCALE dated 3/30/2022 revealed the resident was a high fall risk. Review of the Minimum Data Set Assessment (MDS) dated [DATE] revealed the resident has long and short-term memory problems and s/he has severely impaired cognitive skills for daily decision making. Further review of the MDS Assessment indicated the resident had repeated falls, utilizes a walker and requires a one-person physical assist for transfers, walking within the room, and toileting. Review of a care plan focus area dated 4/11/2022 states in part, [Resident] is at risk for falls related to difficulty in walking .patient ambulating without AD [assistive device]. Further review of the care plan dated 1/30/2023 revealed the resident fell 8 times between 8/30/2022 through 1/29/2023. Additionally, interventions relative to falls included, but are not limited to: -Assist the resident with early get-up if awake. -Reinforce teaching regarding calling for assistance when s/he wants to get up. -Anticipate and meet needs. -Monitor gait and balance. -PT [physical therapy] screen for walker with oxygen, dated 12/31/2022. Record review failed to reveal evidence the above-mentioned interventions were implemented or followed. Additionally, the resident was not currently receiving therapy services including, PT/OT [occupational therapy] between 12/27/2022 through 1/29/2023, the day the resident was sent to the hospital for evaluation after sustaining a fall on 1/29/2023. Record review revealed the following progress notes: -12/31/2022 at 7:11 PM .resident attempt to stand .lost [his/her] balance and landed on [his/her] buttocks . -1/17/2023 at 3:39 PM Authored by the Physician, .Routine Encounter .ongoing .PT/OT .no acute concerns at this time .Resident States [s/he] is feeling well .no complaints .Promote fall and safety precautions . -1/27/2023 at 11:47 AM .Resident fell . -1/29/2023 at 6:54 AM .Noted to be on the ground .R [right] Arm appears to be broken .911 called . -1/31/2023 at 2:17 PM .contacted residents POA [power of attorney] informed writer that [s/he] is unable to be stabilized at this time and is actively dying . During a surveyor interview on 2/9/2023 at 12:14 PM with the resident's POA, she revealed the resident had passed away on 2/2/2023. Review of a facility incident report conducted after the resident fell on [DATE] revealed the resident's room was poorly lit. Additionally, it revealed the resident was confused and had a gait imbalance. During a surveyor interview on 2/8/2023 at 11:58 AM with Registered Nurse, Staff A, she revealed the resident uses a 3 wheeled walker and is on continuous oxygen therapy. She further revealed the resident is impulsive and forgetful, and often goes to the bathroom without his/her walker. During a surveyor interview on 2/8/2023 at 12:16 PM with Licensed Practical Nurse, Staff B, she acknowledged she was the nurse on duty when the fall occurred. She revealed she entered the resident's room at approximately 6:25 AM to administer morning medications to his/her roommate and noted Resident ID #7 seated upright on his/her bed. She further revealed the room was dark and the resident's walker was noted by the dresser which was out of the resident's immediate reach. At approximately 6:45 AM, Nursing Assistant, Staff C, alerted her the resident was noted on the ground in front of the roommate's bureau (which is right before the bathroom door.) Additionally, Staff B revealed she was unaware of the interventions in the resident's care plane that indicated staff were to assist the resident with early get-up if awake and to anticipate his/her needs. During a surveyor interview on 2/9/2023 at 12:58 PM with the Assistant Director of Nursing Services, she revealed residents who are identified as fall risks are discussed during the weekly at-Risk meetings held on Wednesdays. Additionally, residents are also added to the at-Risk report after sustaining a fall. She further revealed appropriate interventions are formulated during the post-fall assessment and the care plan is updated. She was unable to provide evidence the resident was identified and discussed during the weekly at-Risk meetings. She revealed she would expect the care plan to be updated and the interventions followed per the plan of care. Furthermore, she was unable to provide evidence the facility ensured and promoted the safest environment for the resident to prevent or mitigate accidents.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who need [CONDITION(S)] care and tracheal suctioning are provided such care, consistent with professional standards of practice for 1 of 1 residents with a [CONDITION(S)] (an incision in the windpipe made to relieve an obstruction to breathing), Resident ID #1. Findings are as follows: Record review of a community reported complaint sent to the Rhode Island Department of Health on 9/8/2022 submitted by the hospital alleges .EMS [emergency medical services] called to facility for a tracheotomy dislodgement and upon inspection of the stoma [opening in the body] the EMS personnel had found the stoma to be well healed, with no visible opening . Record review revealed the resident was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a nursing note dated 9/8/2022 at 4:28 PM revealed the following . residents [CONDITION(S)] was found dislodged upon the beginning of the shift . Nurse manager, DON [Director of Nurses] notified. 911 called for transfer to .Hospital . Record review of the hospital admission note dated 9/8/2022 and time stamped 10:13 PM revealed in part . the site of the [CONDITION(S)] is closed .stoma essentially almost closed .stoma filled with granulation tissue [new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process.] . During a surveyor interview with the Hospital Medicine Physician on 9/13/2022 at approximately 3:54 PM, he revealed there was no open passage to replace the [CONDITION(S)] tube. He indicated the tract was completely closed and if the [CONDITION(S)] needed to be reinserted a surgical procedure would be required. He stated to the surveyor that it would take anywhere from 24 hours up to two weeks for the tract to completely close. Record review revealed the following facility orders: - An order dated 8/5/2022 for Check for [CONDITION(S)] placement every shift - Last documented as completed on 9/8/2022 day shift - An order dated 8/5/2022 for [CONDITION(S)] care two times a day - Last documented as completed on 9/8/2022 at 8:00 AM During an interview on 9/13/2022 at approximately 9:28 AM with Licensed Practical Nurse, Staff C, who provided [CONDITION(S)] care for this resident on 9/8/2022 , she indicated the last time she saw the resident was between 1:00 PM and 1:30 PM and the [CONDITION(S)] tube was not dislodged at that time. Although the facility had the orders listed above for care of the [CONDITION(S)], documentation that the care was completed and an interview with Staff C indicating the [CONDITION(S)] was in place on 9/8/2022 between 1:00 PM and 1:30 PM this resident was sent and admitted to the hospital for [CONDITION(S)] dislodgment and his/her stoma was essentially almost completely closed. During a surveyor interview on 9/13/2022 at 9:15 AM with Licensed Practical Nurse, Staff E she revealed she did not receive any training on [CONDITION(S)] care before providing care to this resident. She also indicated that she had concerns providing the [CONDITION(S)] care and stated, I feel more training was needed. During an additional surveyor interview on 9/13/2022 at 9:28 AM with Staff C she revealed she did not receive any training on [CONDITION(S)] care prior to taking care of the resident. During a surveyor interview with the Director of Nurses on 9/9/2022 at approximately 12:05 PM she revealed she was called to the resident's room because the residents [CONDITION(S)] tube was dislodged. She indicated she saw the [CONDITION(S)] tube dislodged and the stoma was not open. She indicated she sent the resident to hospital via EMS

Based on record review and staff interview, it has been determined that the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 2 of 2 residents identified, Resident ID's #1 and 2. Findings are as follows: 1. Record review revealed Resident ID #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the August 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - Change [CONDITION(S)] collar every day shift every Wednesday for [CONDITION(S)] care. Additional review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Both of which did not have documented competencies regarding [CONDITION(S)] care. - Change humidification tubing every day shift every Wednesday for [CONDITION(S)] care Additional review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Both of which did not have documented competencies regarding [CONDITION(S)] care. - Check for [CONDITION(S)] placement every shift Review of the above treatment revealed 144 treatments were provided in total. Of those 144 treatments 26 treatments were provided by licensed nursing staff members ( Staff ID's C, D, E, F, G, H, I, J, K, L, M, N, O, P, R, S, T, U, V, X, Y, Z, BB, CC, DD and EE) who did not have documented competencies regarding [CONDITION(S)] care. Record review of the September 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - Change [CONDITION(S)] collar every day shift every Wednesday for [CONDITION(S)] care. Additional review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff C did not have documented competencies regarding [CONDITION(S)] care. - Change humidification tubing every day shift every Wednesday for [CONDITION(S)] care Additional review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff C did not have documented competencies regarding [CONDITION(S)] care. - Check for [CONDITION(S)] placement every shift Review of the above treatments revealed 22 treatments were provided in total. Of those 22 treatments 5 treatments were provided by licensed nursing staff members ( Staff ID's C, J, T, X and BB) who had did not have documented competencies regarding [CONDITION(S)] care. 2. Record review revealed Resident ID #2 was admitted to the facility in August of 2022 with a PleuerX drainage catheter (a thin flexible tube that is placed in the chest to drain fluid from around the lung). Record review of the August 2022 Treatment Administration Record (TAR) for Resident ID #2 revealed in part the following: - [MEDICATION(S)] must be drained twice a week. MON AND THURS if drainage stops, before deciding to remove catheter . Additional review of the TAR revealed this order was completed 1 time in the month of August by Licensed Practical Nurse, Staff D. Staff D did not have documented competencies regarding the PleuerX drainage catheter. Record review of the September 2022 TAR for Resident ID #2 revealed in part the following: - [MEDICATION(S)] must be drained twice a week. MON AND THURS if drainage stops, before deciding to remove catheter . Additional review of the TAR revealed this order was completed twice in the month of September by Licensed Practical Nurse, Staff D and Licensed Practical Nurse, Staff CC. Both of which did not have documented competencies regarding the PleuerX drainage catheter. During an interview with Licensed Practical Nurse, Staff C on 9/14/2022 at approximately 2:00 PM, she revealed that she performed the pleural fluid drainage for Resident ID #2 because his/her assigned nurse did not know how. When asked how Staff C would respond if she walked in the resident's room and found the catheter dislodged/out of place, Staff C was unable to answer the question and indicated she would call the physician. During a surveyor interview with the Director of Nurses on 9/14/2022 at approximately 12:00 PM she was unable to provide evidence of documented competencies regarding the [MEDICATION(S)] catheter. Additionally, she acknowledged that Staff ID 's C, D, E, F, G, H, I, J, K, L, M, N, O, P, R, S, T, U, V, X, Y, Z, BB, CC, DD and EE did not have documented competencies regarding [CONDITION(S)] care.

Based on record review, and staff interview, it has been determined that the facility failed to thoroughly investigate and prevent further abuse for all alleged violations of sexual/verbal abuse for Resident ID #1 and multiple unidentified residents. Findings are as follows: Record review of a community reported incident that was submitted to the Rhode Island Department of Health on 11/22/2021 indicates that sexual inappropriate behaviors were occurring between residents on the secured unit and that staff was told not to document and they are hiding it from the state. Review of facility policy titled, Abuse Neglect, Mistreatment And Misappropriation of Resident Property states in part, it is the policy of the Dawn Hill Home For Rehab and Healthcare to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse .ii. Sexual abuse is non-consensual sexual contact of any type with a resident; sexual harassment, sexual coercion, sexual assault and inappropriate touch. F. Reporting and Response Abuse Policy Requirements: It is the policy of this facility that abuse allegations .are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse .are reported immediately, but not later than 2 hours after the allegation is made . 1) Record review revealed Resident ID #1 was admitted to the facility in March of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) assessment dated on 9/18/2021 revealed a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severe cognitive impairment. Record review of the nursing progress notes revealed the following entries: -11/14/2021, Resident ID #2 observed self- propelling into Resident's ID #1's room. Nurse, Staff A, opened the door and saw Resident ID #2 fondling Resident ID #1's breast. Record review failed to reveal evidence that this incident was thoroughly investigated. During a surveyor phone interview with the Director of Nursing (DON), on 11/22/2021 at 2:26 PM, she stated that this was not brought to her attention and she acknowledged that it should have investigated. 2) Record review revealed Resident ID #2 was admitted to the facility in July of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the nursing progress notes revealed the following entries: - 9/4/2021, Resident ID #2 entered a resident's room and said, I want to .you so bad. Record review failed to reveal evidence that this incident was thoroughly investigated including the identity of the victim. -10/4/2021, resident making signs with his/her hands to a resident of the opposite sex, indicating that s/he wanted to have sex with that resident. Record review failed to reveal evidence that this incident was thoroughly investigated including the identity of the victim. -11/18/2021, Resident ID #2 was in another resident's room of the opposite sex, standing over her/him while s/he was sleeping. Resident was overheard saying, Are you awake? Are you awake? Where's my morning kiss? Record review failed to reveal evidence that this incident was thoroughly investigated including the identity of the victim. -11/18/2021, Approximately three hours later, Resident ID #2 was overheard saying to another resident, You know what I want. I want to suck on your [private part]. Record review failed to reveal evidence that this incident was thoroughly investigated including the identity of the victim. -11/20/2021, Resident ID #2 was seen going into Resident ID #1's room at 4:45 AM. Resident ID #1 stated, [s/he] was kissing me. Record review failed to provide evidence that this incident was thoroughly investigated. 3) Record review revealed Resident ID #3 was readmitted to the facility in October 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the nursing progress notes revealed the following entries: -10/6/2021, overheard stating to a resident, I love you. I want to kiss you all over. Record review failed to reveal evidence that this incident was thoroughly investigated including the identity of the victim. -10/30/2021, Resident ID #3 observed rubbing the hands of a resident while that resident was asleep. Resident later observed holding a different resident's hand and kissing it. An activity aide observed resident rubbing this resident's hand and arm. Resident stated, Thank God [s/he] left [s/he's] rubbing my arms and hands. Record review failed to reveal evidence that these incidents were thoroughly investigated including the identity of the victims. -11/1/2021, Resident also reported to be going in other resident rooms overnight making them uncomfortable . Record review failed to reveal evidence that this incident was thoroughly investigated including the identity of the victim. -11/4/2021, Resident noted with inappropriate sexual behavior with another resident . Record review failed to reveal evidence that this incident was thoroughly investigated including the identity of the victim. -11/5/2021, resident was inappropriately touching other residents this shift. [Resident ID #3] attempted to put a [female/male] resident's hand on [himself/herself] .This was very upsetting for the [male/female] resident. Record review failed to reveal evidence that these incidents were thoroughly investigated including the identity of the victims. -11/8/2021, resident was seen walking up to a resident and kissing them on the lips. Record review failed to reveal evidence that this incident was thoroughly investigated including the identity of the victim. During an interview with the Administrator and the DON on 11/30/2021 at approximately 4:00 PM they were unable to provide evidence of the the names of the victims mentioned above and could not provide evidence that these incidents were thoroughly investigated.

Based on record review and staff interview it has been determined that the facility failed to protect the resident's right to be free from sexual abuse for Resident #1 and multiple unidentified residents. Findings are as follows: Record review of a community reported incident that was submitted to the Rhode Island Department of Health on 11/22/2021 indicates that sexual inappropriate behaviors were occurring between residents on the secured unit and that staff was told not to document and they are hiding it from the state. Review of facility policy titled, The Dawn Hill Home For Rehab and Healthcare Abuse Neglect, Mistreatment And Misappropriation of Resident Property states in part, it is the policy of the Dawn Hill Home For Rehab and Healthcare to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse . ii. Sexual abuse is non-consensual sexual contact of any type with a resident; sexual harassment, sexual coercion, sexual assault and inappropriate touch. 1) Record review revealed Resident ID #1 was admitted to the facility in March of 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress notes revealed the following entry: -11/14/2021, Resident ID #2 observed self- propelling into Resident ID #1's room. Staff A, opened the door and saw Resident ID #2 fondling Resident ID #1's breast. During a surveyor interview with Resident ID #1's family member on 11/23/2021 at 3:26 PM, s/he revealed that s/he was not made aware of Resident ID #1's sexual behaviors. During a surveyor interview with the Director of Nursing (DON), on 11/22/2021 at 2:26 PM, she stated that this incident of sexual abuse should have been reported. She was unable to provide evidence that this incident was reported. 2) Record review revealed Resident ID #2 was admitted to the facility in July of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE] revealed a BIMS score of 2, revealing the resident has severe cognitive impairment. Review of the progress notes revealed the following entries: -9/4/2021, Resident ID #2 asked a certified nursing assistant to lie in the bed so Resident ID #2 could .her out. On this same day Resident ID #2 entered a resident's room and said, I want to .you so bad. -9/5/2021, resident told an aide, I want to suck on a [private part]. -9/15/2021, resident observed looking around to see if anyone is watching before touching a resident's hand of the opposite sex. This [male/female] resident does not want [Resident ID #2] to touch [him/her]. -10/4/2021, resident making signs with his/her hands to a resident of the opposite sex, indicating that s/he wanted to have sex with that resident. -10/28/2021, Resident ID #2 hovering over a resident of the opposite sex. The resident said, Stop It! -11/8/2021, .Increased behaviors of sexual inhibition, exposing [private parts] . -11/14/2021, observed resident entering Resident ID #1's room. Resident ID #1 was observed with her/his shirt up and Resident ID #2 fondling Resident ID #1's breast. -11/18/2021, resident was in another resident's room standing over her/him while s/he was sleeping. Resident was overheard saying, Are you awake? Are you awake? Where's my morning kiss? Later that day the resident was overheard telling Resident ID #2 to leave them alone. Approximately three hours later, resident was overheard saying to another resident, You know what I want. I want to suck on your [private part]. -11/20/2021, resident was seen going into Resident ID #1's room at 4:45 AM. Resident ID #1 stated, [s/he] was kissing me. During a surveyor interview with Staff A on 11/22/2021 at 12:21 PM s/he stated s/he has seen Resident ID #2 fondling, kissing, hand holding, and making sexual gestures to Resident ID #1. During a subsequent surveyor interview with Staff A on 11/23/2021 at 11:09 AM s/he stated that s/he witnessed Resident ID #2 sucking on Resident ID #1's breast and was told by the Unit Manager, Staff D, not to document his/her observation. During a surveyor interview with Certified Nursing Assistant, Staff B, on 11/23/2021 at 11:40 AM, she stated she observed Resident ID #2 in Resident ID #1's room when Resident ID #1's shirt was up and Resident ID #2's mouth was open and close to Resident ID #1's breast. 3. Record review revealed Resident ID #3 was admitted to the facility in October of 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress notes revealed the following entries: -10/6/2021, overheard stating to a resident, I love you, I want to kiss you all over. -10/30/2021, resident observed rubbing the hands of a resident of the opposite sex while that resident was asleep. Resident later observed holding a different resident's hand of the opposite sex and kissing it. An activity aide observed resident rubbing this resident's hand and arm. Resident stated, Thank God [s/he] left [s/he's] rubbing my arms and hands. -11/1/2021, Resident also reported to be going in other resident rooms overnight making them uncomfortable . -11/4/2021, Resident noted with inappropriate sexual behavior with another resident . -11/5/2021, resident was inappropriately touching other residents this shift. [Resident ID #3] attempted to put a [female/male] resident's hand on [himself/herself] .This was very upsetting for the [male/female] resident. Later on resident was redirected from rubbing the shoulders of a different resident [of the opposite sex] who was sleeping. -11/8/2021, resident was seen walking up to a resident and kissing them on the lips. Resident was redirected away from several other residents of the opposite sex during the shift. -11/13/2021, Res [Resident] insistent on entering a [male/female] Res room. Multiple attempts to redirect Res with little effect. Res then attempts to force self into [male/female] Res room . During a surveyor interview with Social Worker, Staff C, on 11/22/2021 at 2:02 PM, she stated she was not aware of Resident ID #'s 1, 2 and 3 sexual behaviors. During a surveyor interview with the the Administrator on 12/01/2021 at approximately 4:00 PM he was unable to provide evidence that Resident ID #1 and the unknown above mentioned residents were kept free from abuse.

Based on record review and staff interview, it has been determined that the facility failed to ensure that cognitively impaired residents received adequate supervision for 3 of 3 sample residents, Resident ID #s 1, 2, 3 and multiple unidentified residents. Findings are as follows: Record review of a community reported incident that was submitted to the Rhode Island Department of Health on 11/22/2021 indicates that sexual inappropriate behaviors were occurring between residents on the secured unit and that staff was told not to document and they are hiding it from the state. 1) Record review revealed Resident ID #1 was admitted to the facility in March of 2021 with diagnoses which include [CONDITION(S)] and anxiety disorder. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severe cognitive impairment. Review of the progress notes revealed the following entries: -11/14/2021, Resident ID #2 observed self- propelling into Resident ID #1's room. Staff A, opened the door and saw Resident ID #2 fondling Resident ID #1's breast. Review of the care plan for Resident ID #1 last revised on 9/28/2021 failed to reveal evidence that this resident had any sexually inappropriate behaviors. There were no interventions in place for sexually inappropriate behaviors. Record review failed to reveal evidence that these residents were adequately supervised, putting these residents and other residents at risk for abuse or potential for abuse. 2) Record review revealed Resident ID #2 was admitted to the facility in July of 2021 with diagnoses which include dementia. Review of a quarterly MDS assessment dated on 10/22/2021 revealed a BIMS score of 2 out of 15, indicating severe cognitive impairment. Review of the progress notes revealed the following entries: -Review of the progress notes revealed the following entries: -9/4/2021, Resident ID #2 asked a certified nursing assistant to lie in the bed so Resident ID #2 could .her out. On this same day Resident ID #2 entered a resident's room and said, I want to .you so bad. -9/5/2021, resident told an aide, I want to suck on a [private part]. -9/15/2021, resident observed looking around to see if anyone is watching before touching a resident's hand of the opposite sex. This [male/female] resident does not want [Resident ID #2] to touch [him/her]. -10/4/2021, resident making signs with his/her hands to a resident of the opposite sex, indicating that s/he wanted to have sex with that resident. -10/28/2021, Resident ID #2 hovering over a resident of the opposite sex. The resident said, Stop It! -11/8/2021, .Increased behaviors of sexual inhibition, exposing [private parts] . -11/14/2021, observed resident entering Resident ID #1's room. Resident ID #1 was observed with her/his shirt up and Resident ID #2 fondling Resident ID #1's breast. -11/18/2021, resident was in another resident's room standing over her/him while s/he was sleeping. Resident was overheard saying, Are you awake? Are you awake? Where's my morning kiss? Later that day the resident was overheard telling Resident ID #2 to leave them alone. Approximately three hours later, resident was overheard saying to another resident, You know what I want. I want to suck on your [private part]. -11/20/2021, resident was seen going into Resident ID #1's room at 4:45 AM. Resident ID #1 stated, [s/he] was kissing me. Review of the care plan for Resident ID #2 last revised on 10/22/2021 revealed that this resident has a history of making inappropriate comments to other residents. This care plan failed to reveal evidence that this resident has sexually inappropriate behaviors. There were no interventions in place for these behaviors. Record review failed to reveal evidence that these residents were adequately supervised, putting these residents and other residents at risk for abuse or potential for abuse. 3) Record review revealed Resident ID #3 was readmitted to this facility in October 2021 with diagnoses which include dementia with behavioral disturbance. Review of a MDS assessment dated on 10/20/2021 revealed a BIMS score of 2 out of 15, indicating severe cognitive impairment. Review of the progress notes revealed the following entries: -10/6/2021, overheard stating to a resident, I love you, I want to kiss you all over. -10/30/2021, resident observed rubbing the hands of a resident of the opposite sex while that resident was asleep. Resident later observed holding a different resident's hand of the opposite sex and kissing it. An activity aide observed resident rubbing this resident's hand and arm. Resident stated, Thank God [s/he] left [s/he's] rubbing my arms and hands. -11/1/2021, Resident also reported to be going in other resident rooms overnight making them uncomfortable . -11/4/2021, Resident noted with inappropriate sexual behavior with another resident . -11/5/2021, resident was inappropriately touching other residents this shift. [Resident ID #3] attempted to put a [female/male] resident's hand on [himself/herself] .This was very upsetting for the [male/female] resident. Later on resident was redirected from rubbing the shoulders of a different resident [of the opposite sex] who was sleeping. -11/8/2021, resident was seen walking up to a resident and kissing them on the lips. Resident was redirected away from several other residents of the opposite sex during the shift. -11/13/2021, Res [Resident] insistent on entering a [male/female] Res room. Multiple attempts to redirect Res with little effect. Res then attempts to force self into [male/female] Res room . Review of the care plan for Resident ID #3 initiated on 10/8/2021 reveals resident has a behavior problem making romantic statements to other residents. The care plan failed to reveal evidence of any interventions for sexual behaviors. Record review failed to reveal evidence that these residents were adequately supervised, putting these residents and other residents at risk for abuse or potential for abuse. During a surveyor interview with the Social Worker, Staff C, on 11/22/2021 at 2:02 PM she revealed that she was not aware of the sexual behaviors of these residents. During a surveyor interview with the the Administrator on 12/01/2021 at approximately 4:00 PM he was unable to provide evidence that Resident ID #1 and the unknown above mentioned residents were adequately supervised.

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, and the residents' choices for 1 of 29 sample residents reviewed for quality of care. Findings are as follows: Record review revealed resident ID #320 was admitted to the facility on [DATE] at approximately 6:15 PM for short term rehabilitation following a 9 day hospitalization beginning with an elective surgery for [REDACTED]. The resident was [AGE] years old with multiple co-morbidities including active [MEDICAL CONDITION] and a history of kidney disease with the presence of a single kidney. The resident had been admitted to the Medical Intensive Care Unit (MICU) after developing postoperative complications including persistent electrolyte abnormalities and [MEDICAL CONDITION]. In the MICU the resident was diagnosed with [REDACTED]. The record indicated that upon admission to the facility the resident refused to wear the Bi-pap as ordered. An admission note written on [DATE] at 9:15 PM states in part, VS (vital signs) obtained and recorded. Pt is 94% (indicating an oxygen saturation level considered to within normal limits)on 2L (indicating the patient was receiving oxygen at a flow rate of 2 liters per minute) when assessed this evening. The record lacked evidence of any vital signs, including oxygen saturation after the 9:15 PM note. Further record review revealed a note written by Staff D, on [DATE] at 03:39 AM which states in part, .3:06-am found without resp (respirations) or heartbeat. daughter mary notified. An interview with Nursing Assistant, Staff E, on [DATE] at approximately 12:00 PM revealed that she had seen the resident in bed from the doorway during her rounds prior to 3:06 AM. An interview with Nursing Assistant, Staff F, on [DATE] at approximately 12:20 PM revealed that she had seen the resident in bed while in the room caring for his roommate, during her rounds prior to 3:06 AM however she had not interacted with the resident, nor obtained any vital signs. An interview with Nursing Assistant, Staff G, on [DATE], at approximately 8:30 AM, revealed she had seen the resident in bed while in the room caring for his roommate, during her rounds prior to 3:06 AM however she had not interacted with the resident, nor obtained any vital signs. An interview with Staff Nurse D on [DATE] at approximately 11:00 AM revealed she had not obtained the resident's vital signs or initiated an assessment of the resident prior to 3:06 AM. An interview with the on-call physician covering resident ID #320 on ,[DATE]-[DATE] revealed that he had received a call regarding the resident at the time of admission to confirm the resident's orders. He stated he was not notified of the resident's refusal to wear the Bi-pap and would expect notification that a resident was refusing their ordered Bi-pap especially in the case of a new admission. The facility failed to inform the attending physician of a significant refusal of care by this newly-admitted resident with recent respiratory compromise. Further there lacked evidence that staff performed ongoing assessment and monitoring of this highly compromised resident during the several hours after his admission until he was found deceased at 3:06 AM.

Based on record review, staff and physician interview, it has been determined that the facility failed to ensure personnel provide basic life support, including CPR (cardiopulmonary resuscitation), to a resident requiring such emergency care, as designated in the resident's advance directives for 1 of 2 sampled residents investigated for death in the facility (ID # 320). Findings are as follows: Record review revealed resident ID #320 was admitted to the facility on [DATE] at approximately 6:15 PM for short term rehabilitation following an elective Transurethral Resection of Bladder Tumor (TURBT). A document in the resident's chart titled Saint Elizabeth's Manor Advanced Directives, was reviewed. The document offers numbered options and directs the resident/designee to Check Appropriate Box. A check mark was placed on a line indicating the resident/designee elected option 1, which reads, Full Code (Resuscitate) (CPR) all Therapeutic interventions prior to and at time of cardio [MEDICAL CONDITION] arrest will be performed. A check mark was also placed on a line indicating the resident selected option 4B, which reads (MONTH) Hospitalize. Below the numbered options, the document directs the resident/designee to Check off who was present during the code status discussion. A check was placed indicating the resident, a second check was placed indicating the agent or the resident's Durable Power of Attorney. The document is signed by the resident's daughter on [DATE], on a line designated Signature of Legal Guardian/Durable Power of Health Care or next of Kin. There is a second signature on a subsequent line designated for a Facility Representative. Further record review revealed a note written by Staff D, on [DATE] at 03:39 AM which states in part, .3:06-am found without resp (respirations) or heartbeat. daughter mary notified. An interview with Nursing Assistant, Staff G, on [DATE], at approximately 8:30 AM, revealed that at approximately 3:00 AM, she entered the room to assist the resident's roommate and she noted the resident appeared to be deceased . She called for Nurse Staff D. Staff G indicated that Staff D assessed the patient and indicated that he had expired. Staff G indicated that at the time, she was unaware of the resident's code status and that Staff D did not raise the issue of the resident's code status or discuss the possibility of beginning CPR and calling 911. An interview with Staff Nurse D on [DATE] at approximately 11:00 AM revealed that she received a nursing report regarding the resident's admission at the start of her shift which included the resident's designated code staus, which was a Full Code. Staff D agreed she went to the resident's room at approximately 3:00 AM she described the resident's clinical condition at that time to include a greyish color, cool to touch, no breath or heart sounds upon auscultation. She added that she had lifted the resident's eyelids and his eyes appeared to be fixed. She did not perform CPR or call 911 as she believed that resuscitation would be unsuccessful given the resident's clinical condition. An interview with the Unit Manager on [DATE] at approximately 11:00 AM revealed it was her expectation that in the event a resident designated a Full Code, was assessed to be unresponsive and without a pulse, that staff would immediately begin CPR and call 911. An interview with the on-call physician covering resident ID #320 on [DATE] revealed that he had received a call regarding the resident at the time of admission to confirm the resident's orders. He stated he had been made aware that the resident had an advanced directive indicating he was a Full Code. He would expect that in the event a resident, designated a Full Code, was discovered to be unresponsive and without a pulse, that staff would initiate CPR and place a call to the covering physician describing the resident's clinical condition. The American Heart Association's Guidelines for CPR and ECC (Emergency Cardiovascular Care) state in part While the general rule is to provide emergency treatment to a victim of [MEDICAL CONDITION], there are a few exceptions where withholding CPR would be considered appropriate: - Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril (eg, exposure to infectious diseases). - Obvious clinical signs of irreversible death (eg, rigor mortis , dependent lividity, decapitation, transection, decomposition). - A valid advance directive, a Physician order [REDACTED].polst.org) indicating that resuscitation is not desired, or a valid Do Not Attempt Resuscitation (DNAR) order. There lacked evidence that the resident met any of these conditions.