Every finding on record at West View Nursing Home, Inc

Based on clinical record review and resident and staff interviews, the facility failed to ensure services were provided in accordance with professional standards for 1 of 1 resident reviewed, Resident ID #1. Specifically, the facility failed to implement physician's orders for prescribed medications following two separate hospital discharges, including a hydrocortisone enema (a medication prescribed to treat rectal inflammation) and Veltassa (a potassium binder prescribed to treat elevated potassium levels). These repeated failures resulted in the resident missing multiple doses of hydrocortisone enemas, experiencing worsening pain, and suffering a relapse of symptoms requiring rehospitalization. The resident also missed two doses of prescribed Veltassa following the second hospital discharge despite having a critically elevated potassium level of 6.1 documented on 7/16/2026. Findings are as follows:Record review of a community complaint submitted to the Rhode Island Department of Health on 7/16/2026 alleged that the complainant's spouse was readmitted to the facility on [DATE] with a physician's order for a steroid enema twice daily for three weeks. The complaint stated that the spouse met with facility staff on 7/9/2026 to confirm the medication would be available upon readmission. However, after the resident returned on 7/10/2026, the medication was not available, resulting in missed doses from 7/10/2026 through the morning of 7/13/2026. The complaint further alleged that the resident experienced uncontrolled pain and required a transfer back to the hospital.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 the physician's orders unless they believe that the orders are in error or would harm the clients.Record review revealed the resident was readmitted to the facility on [DATE] with diagnoses including, but not limited to, noninfective gastroenteritis (inflammation of the stomach), colitis (inflammation of the large intestine), and dependence on renal dialysis (a treatment that filters waste and excess fluids from your blood when your kidneys can no longer do so).Record review of an Annual Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 of 15, indicating the resident is cognitively intact.1. Record review of a hospital document titled, Continuity of Care Adult discharge date d 7/10/2026, revealed a physician's order for Hydrocortisone 100 milligrams (mg)/60 milliliters (ml) enema to be administered twice daily.Record review revealed a physician's order for Hydrocortisone 100 mg/60 ml enema to be administered twice daily for 18 days.Record review of the July 2026 Medication Administration Record (MAR) failed to reveal evidence that the Hydrocortisone rectal enema was administered to the resident on the following dates and times:-7/10/2026- PM dose-7/11/2026-AM and PM dose-7/12/2026- AM and PM dose-7/13/2026-AM doseRecord review of a nursing progress note dated 7/11/2026 indicated the Hydrocortisone enema was not going to be delivered to the facility until 7/13/2026.Record review of the resident's pain assessments and progress notes revealed that the resident reported on a scale of 1-10, moderate to severe rectal pain, on the following dates:-7/10 at 8:09 PM, pain score of 6-7/12 at 7:19 PM, pain score of 5-7/13 at 9:26 AM, pain score of 8-7/13 at 12:58 PM, pain score of 8 -7/13 at 3:45 PM, pain score of 7 -7/14 at 4:03 PM, pain score of 6Record review of the nursing progress notes revealed the following:-7/12/2026 at 11:09 PM, the resident was observed pale in color, feeling weak and fatigued. Additionally, the Hydrocortisone enemas had yet to be delivered from the pharmacy.-7/13/2026 at 10:48 PM, the resident continued to complain of rectal discomfort and was administered an as needed pain medication, Oxycodone 5 mg, with fair effect.-7/14/2026 at 4:36 PM, the resident was complaining of severe pain and that the pain medications were not working. The resident requested to be transferred to the hospital.Record review of the hospital documentation revealed the resident was experiencing persistent pain and fever, and due to the resident missing several hydrocortisone enemas, s/he experienced a relapse in symptoms. Further review revealed that once the resident began receiving the steroid enemas, his/her pain and fever resolved.During a surveyor interview with the resident on 7/20/2026 at 11:30 AM, s/he revealed that s/he was readmitted to the facility on [DATE] from the hospital. Additionally, s/he revealed the facility failed to administer the Hydrocortisone enemas to him/her as ordered; s/he had only been administered one dose. S/he further stated that s/he requested to be transferred to the hospital due to experiencing uncontrollable rectal pain.2. Record review revealed the resident was discharged from the hospital and re-admitted to the facility on [DATE].Record review of hospital documentation revealed a progress note that revealed on 7/16/2026 at 6:45 AM, the resident's potassium level was critically high at 6.1 (a normal range 3.6-5.2) and a repeated level was obtained at 9:21 AM and indicated that it was still elevated at 5.7.Record review of a hospital document titled, Continuity of Care Adult discharge date d 7/18/2026, revealed a physician's order for Veltassa 8.4 grams daily. Record review revealed a physician's order dated 7/19/2026 for Veltassa to be administered once a day.Review of the July 2026 MAR failed to reveal evidence that the resident received the Veltassa as ordered on 7/19 and 7/20/2026.During a surveyor interview with the resident on 7/20/2026 at 11:30 AM, s/he revealed that after being discharged from the hospital on 7/18/2026, s/he was prescribed Veltassa and s/he had not received the Veltassa on 7/19 or on 7/20/2026, because it has not been delivered by the pharmacy.During a surveyor interview on 7/20/2026 at 12:03 PM with Certified Medication Technician, Staff A, she acknowledged that she did not administer the Veltassa to the resident on 7/20/2026 because it was not available. Staff A revealed that she documented a code of 12, which indicates the facility is waiting for the pharmacy to deliver the medication, because the medication was not available at the time of administration.During a surveyor interview on 7/20/2026 at 12:15 PM with the Director of Nursing Services, in the presence of the Administrator, she acknowledged that the resident did not receive the Hydrocortisone enemas as ordered. Additionally, she revealed that she was unaware the resident had not received Veltassa on 7/19 and 7/20/2026, until it was brought to her attention by the surveyor.During a surveyor interview on 7/20/2026 at 1:00 PM with the Nurse Practitioner, she revealed that she was not notified that the resident missed his/her Hydrocortisone enemas on 7/10, 7/11, 7/12, and the morning dose of 7/13/2026. She further indicated that she would have expected the facility staff to contact the on-call physician to notify them that the medication was not available or to arrange for the resident to return to the hospital, if necessary. Additionally, she revealed that she was unaware that the resident did not receive the prescribed Veltassa. The facility's failure to ensure the resident's Hydrocortisone enemas were available upon his/her readmission to the facility, resulted in Resident ID #1 experiencing moderate to severe rectal pain and required rehospitalization as a result.

Based on clinical record review and staff interview, the facility failed provide services that meet professional standards relating to following the prescribed physical therapy treatment plan for 1 of 2 Residents reviewed, ID #1. Resident ID #1 sustained a left femoral (the long bone of the upper leg) fracture when a Physical Therapy Assistant (PTA) performed rotational exercises of the resident's left hip that were not included in the resident's therapy treatment plan. The facility's investigation determined that the PTA failed to follow the established treatment plan and performed interventions outside the scope of the treatment directives. Following the incident, the facility immediately removed the PTA from resident care duties pending the outcome of the investigation and provided education to all therapy staff regarding adherence to therapy plans and the requirement to seek clarification when treatment instructions are unclear. Surveyor verification confirmed these corrective actions had been implemented prior to the survey, and no evidence was identified that the deficient practice continued to exist at the time of the survey. Findings are as follows:Record review of facility reported incident submitted to the Rhode Island Department of Health on 5/22/2026 states in part, .Resident was found to have closed left femoral fracture. X ray imaging done in facility. Sent to [NAME] Hospital for further evaluation. Injury etiology remains unknown but early investigation may show possible link between therapy treatment provided and the injury .Clinical record review for Resident ID #1's revealed that s/he was admitted to the facility in December of 2025 with diagnoses of, but not limited to nontraumatic intra cerebral hemorrhage, cerebral edema, compression of brain and cognitive communication deficit. Additionally, record review revealed that the resident is nonverbal and unable to make his/her needs known. Clinical record review of Resident ID #1's Physical Therapy PT Evaluation & Plan of Treatments revealed the following: - certification period 12/18/2025 - 1/14/2026 with a short-term goal for the resident to increase active movement of his/her lower left extremity with range of motion (hip rotation) and strengthening exercises with a target date of 12/31/2025. - certification period 12/23/2025 - 1/19/2026 revealed a short-term goal for the patient to continue with range of motion (hip rotation) and strengthening exercises. - certification period 12/18/2025 - 4/13/2026 revealed a short-term goal revealed a short term to discontinue with range of motion (hip rotation) and strengthening exercises. - certification period 5/8/2026 - 6/4/2026 revealed a short-term goal for the patient to improve left knee extension (extension and retraction of the lower leg) and hip extension (raising and lowering the upper leg towards the chest) exercises to with a target a date of 5/21/2026.- certification period 5/8/2026 - 6/4/2026 revealed that the Resident ID #1 had a left hip limited internal and external rotation of 15 degrees in each direction from a neutral position. A left hip external rotation of 15 degrees is an outward turning of your left thigh away from your body's midline. Compared to the standard or normal adult range of 40 degrees to 60 degrees, 15 degrees indicates a significantly limited or restricted range of motion. Clinical record review of Resident ID #1's Physical Therapy Treatment Encounter Note(s) failed to reveal evidence that rotational exercises of the resident's left hip were indicated in any of the plans of treatment. Record review of the facility's 5-day investigation report revealed that the facility's review of the therapy documentation revealed that the Physical Therapy Assistant (PTA) that had worked with the resident was distraught, as she heard a pop sound while doing therapy on the patient. Additionally, the report revealed that the PTA did not properly follow the plan of care for Resident ID #1, as the plan of care did not have a goal or directive to rotate the resident's left hip. Furthermore, the report revealed that it was when the resident's left hip was being rotated, that the resident sustained the femur fracture to his/her left leg. During surveyor interviews with the Certified Occupational Therapy Assistant (COTA) in the presence of the Administrator on 6/11/2026 at approximately 12:00 PM, she indicated that she reviewed the incident and all documentation regarding the resident's plan of care lacked sufficient information which left room for the PTA to interpret what the expected exercises were that should have been conducted with the resident. She further indicated that it is out of the scope of practice for a PTA to interpret a plan of treatment and would have expected the PTA to seek clarification prior to conducting the exercises. During an interview conducted with the Administrator on 6/11/2026 at approximately 12:30 PM, he confirmed that the facility implemented corrective actions following the incident, including staff education and personnel actions, and that these measures had been implemented prior to the survey.a. The Physical Therapy Assistant (PTA) involved in the resident's care was suspended pending the outcome of the facility's investigation.b. Education was provided to all therapy staff regarding adherence to residents' plans of care, including the requirement to follow prescribed treatment interventions and seek clarification when treatment directives are unclear.This deficient practice resulted in a severe and avoidable injury to a highly vulnerable resident who was nonverbal and unable to advocate for him/herself. The facility's own investigation determined that a Physical Therapy Assistant performed a left hip rotation exercise that was not included in the resident's plan of care and was outside the PTA's authority to independently interpret. During the unauthorized maneuver, a pop was reportedly heard, and the resident subsequently sustained a left femoral fracture requiring hospital evaluation. Despite the resident's significantly limited left hip range of motion and complex neurological impairments, the facility failed to ensure that therapy services were provided in accordance with the treatment plan and accepted professional standards of practice. This failure exposed the resident to actual harm and demonstrates a serious breakdown in clinical oversight, care planning, and the delivery of rehabilitative services.

Based on clinical record review and staff interview, the facility failed to provide respiratory care in accordance with professional standards of practice for 1 of 1 resident reviewed. Emergency Medical Services (EMS) observed Resident ID #1 receiving oxygen at 5 liters per minute (LPM) via a non-rebreather mask, a delivery method that requires a minimum flow rate of 10 LPM to maintain proper reservoir inflation and effective oxygen delivery. The use of a non-rebreather mask below the required flow rate rendered the device ineffective, resulting in inadequate oxygenation and placing the resident at immediate and significant risk for respiratory failure, hypoxia, and cardiopulmonary decompensation.As a result of this deficient practice, Resident ID #1 experienced clinical deterioration requiring emergent transfer to the emergency room (ER), where the resident was admitted with metabolic acidosis, a serious life-threatening condition characterized by excessive acid accumulation in the body that may result from prolonged hypoxia. Findings are as follows:Record review of a facility reported incident sent to the Rhode Island Department of Health on [DATE], revealed that on [DATE], the resident's Novolog order was decreased from 5 units to 4 units, to be given three times daily. However, the order was incorrectly transcribed for day, evening, and night shifts (7:00 AM - 3:00 PM, 3:00 PM - 11:00 PM, and 11:00 PM - 7:00 AM). Following an insulin dose at 12:45 AM, the resident's blood sugar dropped to a dangerously low level of 43 milligrams/deciliter (mg/dL) (severe hypoglycemia- normal blood sugar levels are 70-100), requiring emergency hospital transfer.According to the ScienceDirect Journal article, titled Emergency Oxygen Administration, dated 2008, states in part, .Non-Rebreather Mask 1. The non-rebreather mask is the first choice when considering constant flow supplemental oxygen in an acute medical emergency. It consists of a mask, reservoir bag, and two or three one-way valves, one separating the reservoir from the mask and the other one or two on the sides of the mask. Oxygen flows into the reservoir bag so that when the [resident] inhales, he or she inhales O2 from the reservoir. The one-way valves on the sides of the mask keep air from coming into the mask and diluting the O2. When the [resident] exhales, expired air goes out of the mask through the one or two valves on the face and is prevented from entering the reservoir .3. To use the mask, it is attached to the O2 supply at a flow rate of 10 to 15 liters/minute. The reservoir bag must be inflated or primed before placing it on the person .Care must be taken to not allow the O2 supply to be depleted while the mask is on the person. Because of the one-way valves, if there is no O2 supply, suffocation may result .Record review of the facility policy titled Oxygen Administration states in part, .If using a Non-rebreather Mask: This method is a high-concentration oxygen delivery device used in acute emergencies for patients who can breathe spontaneously but need high levels of oxygen. An oxygen cylinder with a 15L gauge must be used. 10L/min is the minimum to prevent rebreathing of CO2 [carbon dioxide] and 15L is maximum.Record review revealed the resident was admitted to the facility in August of 2024 with diagnoses including, but not limited to, type 2 diabetes mellitus, dementia, and sleep apnea.Record review of a progress note dated [DATE] at 6:45 AM authored by Registered Nurse, Staff A, revealed the resident had a hypoglycemic episode (a condition where blood sugar drops below 70 milligrams/deciliter [mg/dL]. Severe hypoglycemia can cause seizures, may lead to unconsciousness, maybe life threatening, or cause death). The resident's oxygen level (SpO2 - peripheral oxygen saturation that measures the percentage of oxygen-saturated hemoglobin in the blood with the normal reading of 95% to 100%. Readings below 90% is considered hypoxemia which can be dangerous and often signals a serious respiratory issue) dropped to a dangerously low level of 82% on room air, indicating hypoxemia. Staff A administered 5 LPM of supplemental oxygen and the emergency responders arrived to transport the resident to the ER.Record review of a statement dated [DATE] at 12:32 PM written by Staff A revealed that she responded to the resident's hypoglycemic emergency with assistance from Licensed Practical Nurse Staff D, who initiated supplemental oxygen at 5 LPM. Staff A further stated that she subsequently transitioned the resident to a non-rebreather mask while maintaining the oxygen flow at 5 LPM. This indicates an inappropriate flow rate for the device, as non-rebreather masks require a minimum of 10 LPM to adequately fill the reservoir bag and prevent rebreathing of exhaled carbon dioxide. Maintaining oxygen at 5 LPM in this delivery system may result in inadequate oxygenation and CO2 rebreathing, thereby placing the resident at risk for clinical deterioration and respiratory compromise.During a surveyor interview on [DATE] at 1:58 PM, Staff A confirmed she cared for the resident during the 11:00 PM to 7:00 AM shift on [DATE] into [DATE]. She revealed that at 6:45 AM, she found the resident pale and unresponsive with severe hypoglycemia and hypoxemia (82% SpO2). Staff A acknowledged that she applied a non-rebreather mask at 5 LPM. Staff A admitted that she was unaware that this mask requires a minimum of 10 LPM to prevent the rebreathing of CO2. She further acknowledged that she failed to recheck the resident's oxygen levels before EMS arrived.Record review of the Rhode Island Emergency Medical Services (EMS) report dated [DATE] at 7:20 AM revealed that emergency responders were dispatched to the facility for Resident ID #1, who was unresponsive and not breathing. Upon arrival at 7:29 AM, EMS found the resident with snoring respirations (agonal breathing; occurs when someone who is not getting enough oxygen is gasping for air. It's not true breathing. It's a natural reflex that happens when your brain is not getting the oxygen it needs to survive. Agonal breathing is a sign that a person is near death) and an SpO2 (peripheral oxygen saturation; is the measurement of the percentage of oxygen-saturated hemoglobin in the blood, a normal reading falls between 95% to 100%) of 77% (low) while facility staff provided only 5 Liters Per Minute (LPM) of oxygen via a non-rebreather mask (the required oxygen flow rate for the use of this mask is a minimum of 10 liters/minute). Once EMS increased the oxygen flow rate to an appropriate level, 15 LPM, the resident's SpO2 improved to 99%. The resident was then transferred to the emergency room.Review of the emergency room (ER) records dated [DATE] indicated that the resident's venous blood gas results were abnormal, with a pCO (partial pressure of carbon dioxide) level of 54 mmHg (normal range: 41-51 mmHg) and a blood pH level of 7.21 (normal range: 7.31-7.45), indicating acid-base imbalance. Further record review revealed that the resident was diagnosed with metabolic acidosis, a serious condition characterized by excessive acid accumulation in the body fluids, which may result from inadequate oxygenation or severe hypoglycemia.During a surveyor interview on [DATE] at 3:57 PM with the Director of Nursing Services, the Administrator, and the Regional Nurse, they were unable to provide evidence that respiratory services were provided consistent with professional standards of practice.During a surveyor interview on [DATE] at 9:14 AM with the resident's physician, Staff E, he revealed that he would expect that staff would know how to use the non-rebreather masks.The facility failed to ensure the safe provision of respiratory care in accordance with professional standards of practice, resulting in Resident ID #1 receiving oxygen via a non-rebreather mask at an insufficient flow rate of 5 LPM instead of the required minimum of 10 LPM. This inappropriate use of the device compromised its intended function, resulting in inadequate oxygen delivery and potential rebreathing of carbon dioxide. This failure contributed to hypoxemia and respiratory compromise requiring emergency medical intervention and hospital transfer. As a result, Resident ID #1 was placed at immediate risk for serious harm, serious impairment, serious injury or death due to staff failure to apply basic clinical knowledge and adhere to established standards for safe oxygen administration. Cross reference F 658

Based on clinical record review, and staff interview, the facility failed to ensure care and services were provided in accordance with professional standards of clinical practice for 1 of 3 residents reviewed receiving insulin therapy for diabetes mellitus, Resident ID #1. Specifically, the facility failed to ensure a complete and clinically appropriate insulin order was obtained, accurately transcribed, and safely administered, resulting in the resident receiving rapid-acting insulin during overnight hours without meal intake, causing severe hypoglycemia requiring emergent hospital transfer. Findings are as follows:Record review of a facility reported incident sent to the Rhode Island Department of Health on 5/1/2026, revealed that on 4/29/2026, the resident's Novolog order was decreased from 5 units to 4 units, to be given three times daily. However, the order was incorrectly transcribed for day, evening, and night shifts (7:00 AM - 3:00 PM, 3:00 PM - 11:00 PM, and 11:00 PM - 7:00 AM). Following an insulin dose at 12:45 AM, the resident's blood sugar dropped to a dangerously low level of 43 milligrams/deciliter (mg/dL) (severe hypoglycemia- normal blood sugar levels are 70-100), requiring emergency hospital transfer.Record review revealed the resident was admitted to the facility in August of 2024 with diagnoses including, but not limited to, type 2 diabetes mellitus, dementia, and sleep apnea.Record review of the manufacturer's instruction manual for Novolog Insulin Aspart Injection 100 units/milliliter (units/mL) last revised in February of 2023, states in part, .NOVOLOG is rapid acting human insulin.Inject subcutaneously within 5-10 minutes before a meal.WARNINGS AND PRECAUTIONS.Changes in an insulin regimen.may affect glycemic control and predispose to hypoglycemia [a condition where blood sugar drops below 70 mg/dL.the most common adverse reaction of all insulins, including NOVOLOG. Severe hypoglycemia can cause seizures, may lead to unconsciousness, maybe life threatening, or cause death.Make any changes to a patient's insulin regimen under close medical supervision with increased frequency of blood glucose monitoring.1. Review of the [NAME] Nursing Procedures Ninth Edition (2023), states in part, SAFE MEDICATION ADMINISTRATION PRACTICES.An adverse drug event (ADE) is defined as harm to the patient, including.physical harm.that results from a medication error. A medication error is a mistake that occurs during medication administration process.A preventable ADE occurs as a result of a clinician error or a systematic error and thus could have been prevented.Verifying the medication order.Verify the essential elements of the medication order are present, including the patient's name, the date and time the order was written, the name of the drug to be administered, the drug dosage, the route of administration, the frequency of administration.specific instructions for use (when applicable).According to Fundamentals Of Nursing 7th Edition by [NAME], Lillis, Lemone, and [NAME] (2011), the patient's full name is required in transcribing medication orders.Record review of a progress note authored by the Certified Family Nurse Practitioner, Staff C, on 4/28/2026 at 11:45 AM, revealed that the resident's morning blood sugars from 4/19/2026 through 4/28/2026 were between 66 -99 mg/dL. The resident had one episode where his/her blood sugar was 59 mg/dL. A new order was initiated on 4/28/2026 to decrease the Novolog from 5 units to 4 units three times daily.Review of the April 2026 Medication Administration Record (MAR) revealed a physician's order to administer Novolog Solution 100 unit/mL 5 units subcutaneously three times a day with the timing of after breakfast, after lunch, and in the evening at 6:00 PM was discontinued on 4/28/2026 at 4:19 PM. A new order was provided on 4/28/2026 at 11:00 PM to administer Novolog Solution 100 unit/mL three times a day with the timing of every shift for 7:00 AM - 3:00 PM, 3:00 PM - 11:00 PM, and 11:00 PM - 7:00 AM.During a surveyor interview conducted on 5/1/2026 at 1:00 PM, Staff C acknowledged that she initiated a new order to decrease the resident's Novolog dosage from 5 units to 4 units three times daily. She stated that her intent was only to change the dosage amount while maintaining the existing administration times of 8:00 AM, 1:00 PM, and 6:00 PM with meals. Staff C further revealed that she did not intend for the resident to receive a dose of rapid-acting Novolog insulin at midnight, which was the dose administered by Staff A on 4/29/2026 at approximately 12:30 AM. She added that she had written the order on a plain white sheet of paper and provided it to the nurse assigned to the resident at that time.Record review revealed a plain white paper uploaded in the resident's Electronic Medical Record (EMR) which revealed the following medication orders: .3. DC [discontinue] 5 units of aspart. 4. Start Aspart 4 units TID [three times a day]. Further review revealed that the handwritten medication order lacked essential elements necessary to minimize the risk of an adverse drug event (ADE), including the resident's first name, the date and time the order was written, the route of administration, and specific instructions clarifying that Staff C intended for the resident to receive 4 units of Novolog three times daily with meals, rather than three times daily every shift, which was how the order was ultimately transcribed. During a follow-up interview conducted on 5/4/2026 at 9:27 AM, Staff C acknowledged that she failed to specify the administration timing in the Novolog order she wrote on 4/28/2026. She stated that she believed it was understood that a rapid-acting insulin ordered three times daily would be administered with meals at breakfast, lunch, and dinner when the resident consumed food to assist with blood glucose regulation. Staff C further stated that her only intention was to decrease the Novolog dose from 5 units to 4 units and that she did not intend to change the established administration times.Staff C additionally acknowledged that she would not expect staff to administer a rapid-acting insulin dose in the middle of the night without first assessing the resident's blood glucose level or providing a meal with the medication. She stated that she did not receive any requests for clarification regarding her medication order from Registered Nurse Staff B, who transcribed the order, or from Staff A, who administered the Novolog on 4/29/2026 at approximately 12:30 AM.2. According to Fundamentals Of Nursing 7th Edition by [NAME], Lillis, Lemone, and [NAME] (2011), it is a nursing responsibility to check that times for medication administration correspond to safe practice for that drug. Nurses are legally responsible for carrying out the orders of the physician in charge of a patient unless an order would lead a reasonable person to anticipate injury if carried out. Nurses should question any physician order that is contraindicated by normal practice and/or contraindicated by the patient's present condition.Record review of a nursing progress note dated 4/28/2026 at 4:46 PM authored by Registered Nurse, Staff B, revealed that she received the order from Staff C to discontinue the Novolog 5 units and start the Novolog 4 units three times a day.During a surveyor interview conducted on 5/4/2026 at 9:00 AM, Staff B acknowledged that she received the above medication orders from Staff C written on a plain white sheet of paper and transcribed the order into the EMR as TID, meaning three times daily. She stated that she sought clarification from Staff C regarding the order and alleged that Staff C instructed her to enter the order exactly as written on the paper as TID, without specifying whether the medication was to be administered three times daily with meals or every shift.Further interview with Staff B revealed that she also sought assistance from an agency nurse when entering the order and was similarly instructed to enter the Novolog order as written on the plain white paper. When asked whether she questioned the appropriateness of scheduling a rapid-acting insulin, such as Novolog, for administration at 11:00 PM, Staff B stated that she was a new nurse and entered the order as directed by the nurse practitioner and the agency nurse.3. Record review of the Fundamentals Of Nursing 7th Edition by [NAME], Lillis, Lemone, and [NAME] (2011), states in part, .Questioning the Medication Order. Nurses are legally responsible for the drugs they administer. Any drug order suspected to be in error should be questioned. The suspected error may be in any part of the order. When preparing to administer a medication, ask: Do the patient's condition, symptoms, health status warrant receiving this medication? Does it make sense for the patient to have this medication? On occasion, the nurse may not think that there is an error in the order but may not understand why the medication has been prescribed. In such instances, ask the prescriber how the order relates to the patient's plan of care. This may prevent a medication error if the wrong medication has been ordered.The nurse is also responsible for double checking the dosage and appropriateness of the medication.Record review of the facility policy titled Medication Administration; Safety with an effective date of 4/7/2008, states in part, .Residents shall receive medications in a safe and timely manner and in accordance with established regulations and guidelines.Should there be any doubt concerning the administering of medication(s), the physician's order must be verified before the medication is given.Review of the April 2026 Medication Administration Record (MAR) revealed a medication order for Novolog Solution 100 units/mL, 4 units every shift, with a start date and time of 4/29/2026 at 11:00 PM. Further review revealed that the dose was documented as administered by Registered Nurse Staff A.Record review of a nursing progress note from 4/29/2026 at 6:45 AM, authored by Staff A, describes an emergency response after the resident's blood sugar dropped to 43 mg/dL. Staff A found the resident pale, unresponsive, and with a dangerously low oxygen level of 82% (normal level of 95% to 100%). Emergency Medical Services was notified and upon arrival, emergency responders noted the resident's blood sugar had risen slightly to 63 mg/dL, and they transferred the resident to the emergency room (ER) for further treatment.During a surveyor interview conducted on 5/1/2026 at 11:51 AM, Staff A acknowledged that she administered rapid acting insulin to the resident just after midnight on 4/29/2026. Staff A admitted that she did not assess the resident's blood glucose level or provide a snack before or after administering the Novolog, stating that she was following the provider's order as entered. She further acknowledged that she did not question the appropriateness of administering a rapid-acting insulin during the nighttime hours without a meal and failed to monitor the resident's blood glucose level. Record review of the ER note dated 4/29/2026 revealed the resident arrived o the ER at 7:40 AM and had a blood sugar level of 52 mg/dL and was admitted with a diagnosis of hypoglycemia and metabolic acidosis (a serious medical condition characterized by an excessive buildup of acid in the body fluids which may be caused by low oxygen or low blood sugar).During a surveyor interview on 5/4/2026 at 9:14 AM with the resident's physician, Staff E, he revealed that he would expect the Nurse Practitioner to write a complete order with all its components necessary to prevent an adverse drug event. Additionally, he would expect the nurses to know that a rapid-acting insulin should be given with meals, or at minimum, assess the resident's blood sugar if it is clinically indicated when administering a rapid-acting insulin in the middle of the night without offering a meal or a snack. Lastly, he would expect nurses to know that the appropriate scheduling times for a rapid-acting insulin is usually within breakfast, lunch, and dinner, and that any other order that was scheduled outside those times should have been reconciled with him or another provider.During a surveyor interview on 5/4/2026 at approximately 10:00 AM with the Director of Nursing Services, the Administrator, and the Regional Nurse, they were unable to provide evidence that the facility staff provided care consistent with professional standards of practice related to writing, transcribing, and administering of a rapid-acting insulin medication order.The facility failed to ensure the safe writing, transcription, clarification, reconciliation, and administration of a rapid-acting insulin medication order, resulting in the resident receiving Novolog at an inappropriate time without blood glucose monitoring or concurrent nutritional intake. This failure led to severe hypoglycemia requiring emergency hospitalization. As a result, Resident ID #1 was placed at risk for serious harm, serious impairment, or death. Facility staff failed to exercise clinical judgment and adhere to fundamental standards of safe medication administration, as the use of rapid-acting insulin without concurrent food intake is contraindicated and places a resident at immediate risk for hypoglycemia and loss of consciousness.During a surveyor interview with the Administrator on 5/4/2026 at approximately 1:45 PM the Administrator explained to the surveyor that the facility had already corrected and implemented a plan for this deficient practice. He provided the surveyor with an immediate removal plan which included:-The conducting of a root cause analysis that determined the etiology of variables that lead to the improper insulin administration. -All licensed nurses were educated concerning the transcription of orders.-All providers were educated on what a complete order is and the proper transcription of an order.-An audit of all residents receiving short acting insulin was conducted to ensure that insulin is administered with meals and that blood sugars are checked prior to the administration of insulin. -The education provided to all licensed nursing staff has been added to the new hire orientation process for the onboarding of licensed nurses. The Administrator alleged compliance as of 4/30/2026; which was verified by the surveyor. Therefore, this deficient practice will be cited under F 658 as past noncompliance at a scope and severity of J. Cross reference F 695

Based on surveyor observation, record review, and staff interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety relative to the main kitchen and the satellite kitchenette.Findings are as follows:1. Record review of the 2022 Food Code published by the U.S. Food and Drug Administration Section 4-501.114 reads in part, a chemical Sanitizer used in a SANTIZING solution for a manual operation shall meet the criteria specified (C) A quaternary ammonium compound shall (2) have a concentration.as indicated by the manufacturer's use by directions.Record review of manufacturer's directions for the use of a quaternary ammonium solution as a sanitizer recommends the pH (a measure to determine the acidity or basicity of a solution based on the number of hydrogen ions in the solution) level should read between 200 and 400 PPM (parts per million).During a surveyor observation on 3/22/2026 at approximately 9:00 AM, of the main kitchen, the 3-bay sink was being used to wash and sanitize pots and pans. The test strip used to test the sanitizing solution failed to register a pH level, indicating the pots and pans were not being sanitized. During a surveyor interview immediately following the above observation with the Director of Food Service (FSD), he revealed that the sanitizing agent used is a quaternary ammonium and that the pH level of the sanitizing solution did not register the appropriate reading.During a surveyor observation on 3/23/2026 at approximately 11:10 AM, of the main kitchen, revealed a sanitizing container that held a wet cloth. The test strip that was used to test the sanitizing solution failed to register a pH level.During a surveyor interview immediately following the above-mentioned observation with the FSD, he acknowledged that the sanitizing solution did not register a pH level.2. Review of the 2022 Food Code published by the U.S Food and Drug Administration Section 4-602.11(A) states in part, Equipment food-contact surfaces and utensils shall be cleaned (4) Before using or storing a FOOD TEMPERATURE MEASURING DEVICE.During a surveyor observation on 3/26/2026 at approximately 11:45 AM, Dietary Cook, Staff F, was observed taking a thermometer from his pant pocket and inserted the thermometer into a slice of pizza to test its temperature. Additionally, Staff F failed to clean the thermometer before he took the temperature of the pizza. 3. Review of the 2022 Food Code published by the U.S. Food and Drug Administration Section 4-601.11 (C) reads in part, .non-contact surfaces of equipment shall be free of an accumulation of .other debris .During a surveyor observation on 3/22/2026 at approximately 8:45 AM, of the main kitchen, the following was observed:grease spills along the sides of the fryolatorlower shelves of worktables with food crumbsthree food carts with food crumbs on the shelvesfive food transport carts with debris noted along the lower rim and cornersDuring a surveyor observation on 3/22/2026 at approximately 9:00 AM, of the satellite kitchenette, the following was revealed:[NAME] Air refrigerator unit with dried food spills along the sides and the refrigerator door gaskets had significant build-up of a black substance.4. Review of the 2022 Food Code published by the U.S Food and Drug Administration Section 6-101(A)reads in part, .materials for indoor floor, wall shall be.EASILY CLEANABLE for areas where FOOD ESTABLISHMENT operations are conducted.During a surveyor observation on 3/22/2026 at approximately 8:45 AM of the main kitchen, the following was observed:The walls that surround the dish room area had noticeable streaks of a black substanceThe floors behind all kitchen equipment, stove, fryolator, and reach in refrigerators had a buildup of black colored grimeThe corners of the floors had a buildup of a black colored grimeDust accumulation was noted along the piping behind the stoveDuring a surveyor interview immediately following the above-mentioned observation with the FSD, he acknowledged the black grime in the corners of the floor and behind the mentioned appliances. He also acknowledged the dust accumulation along the pipe behind the stove. 5. Review of the 2022 Food Code published by the U.S Food and Drug Administration Section 2-402.11 (A) states in part, FOOD EMPLOYEES shall wear hair restraints.that are designed and worn to effectively keep their hair from contacting exposed FOOD, clean EQUIPMENT, UTENSILS.During surveyor observations of the satellite kitchenette, on the following dates and times, Dietary Aide, Staff G, was serving food for residents in the main dining room and she was noted to be wearing a hair net, which failed to cover the front portion of her hair:3/23/2026 at 11:30 AM3/24/2026 at 11:45 AM3/25/2026 at 11:45 AM3/26/2026 at 11:50 AMDuring a surveyor interview on 3/26/2026 at approximately 11:50 AM with the FSD, he acknowledged the equipment that needed cleaning, the cook who failed to sanitize the thermometer before testing the temperature of the pizza and the dietary aide who was not wearing her hair restraint appropriately.

Based on clinical record review and staff interview, the facility failed to ensure that resident records are complete and accurately documented for 1 of 1 resident reviewed for hemodialysis (a treatment that removes excess fluid, waste, and toxins from the blood when the kidneys are no longer functioning properly), Resident ID #39.Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, .The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients .Record review revealed the resident was readmitted to the facility in January of 2026 with diagnoses including, but not limited to, end stage renal disease and dependence on renal dialysis.Record review revealed the resident was on a 1500 milliliter fluid restriction daily.Further record review revealed a physician's order dated 2/4/2026 to total the 24-hour fluid intake, which is to be completed on third shift between 11:00 PM to 7:00 AM.Review of the March 2026 Licensed Nurse Administration Record revealed the resident's daily fluid intake was not accurately totaled, for 24 out of 24 opportunities, until this concern was brought to the facility's attention by the surveyor.During a surveyor interview on 3/25/2026 at 9:59 AM with Licensed Practical Nurse, Staff H, she acknowledged the above order and acknowledged that the amounts documented do not accurately reflect the resident's 24-hour fluid intake.During a surveyor interview on 3/25/2026 at 10:53 AM, with the Director of Nursing Services, she acknowledged the inaccurate documentation and revealed that she would expect third shift nurses to accurately calculate the residents' total 24-hour fluid intake.Record review revealed a physician's order dated 3/25/2026, after this concern was brought to the facility's attention by the surveyor, which states to Add all fluid intake for all 3 shifts document total for 24 hours.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that services provided by the facility meet professional standards of quality relative to following physician's orders for 1 of 2 residents observed for wound care, Resident ID #4.Findings are as follows:Review of an undated facility policy titled, Clean Dressing Technique states in part, PROCEDURE: 1. Check the physician order for current, correct treatment .Record review revealed Resident ID #4 was readmitted to the facility in August of 2025 with a diagnosis including, but not limited to, brain damage.Record review revealed s/he has a wound to his/her right thumb and is followed by a wound specialist.Review of a physician's order dated 3/2/2026 indicated to cleanse his/her right thumb with wound cleanser, pat dry, apply skin prep to the perimeter of the wound, then apply calcium alginate with silver (an antibiotic treatment) to the wound bed, and to cover with a foam dressing daily and as needed.During a surveyor observation on 3/24/2026 at 10:06 AM of the resident's right thumb dressing change, Registered Nurse (RN), Staff C, failed to apply the calcium alginate with silver as ordered. During a surveyor interview immediately following the above observation with Staff C, she acknowledged that she failed to apply the calcium alginate with silver as ordered. During a surveyor interview on 3/24/2026 at 1:20 PM with the Director of Nursing Services, she revealed that she would expect the physician's order to be followed.

Based on clinical record review, and staff and resident interviews, the facility failed to allow a resident to participate in his or her treatment for 1 of 2 residents reviewed, relative to the resident requesting a hospital transfer, Resident ID #25. Findings are as follows:Review of a facility policy titled, Resident Rights last revised 3/2017 states in part, .Respect the right of the resident/patient and/or their designated representative to participate in and make healthcare decisions.Record review revealed that the resident was admitted to the facility in September of 2025 with diagnoses including, but not limited to, chronic respiratory failure and anxiety.Review of a Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 10 of 15 indicating moderate cognitive impairment.Review of a progress note dated 3/19/2026 revealed that the resident complained of chest pain and was medicated with nitroglycerin (a medication prescribed to prevent or treat chest pain) 0.4 milligrams without any relief. Additionally, the note revealed that the resident requested to go to the hospital. Further review revealed that the resident was treated with oxycodone (a pain medication) and clonazepam (an antianxiety medication), and the resident fell asleep. Finally, the progress note revealed that the resident was not transferred to the hospital.Review of a progress note dated 3/20/2026 revealed that the resident was angry that s/he did not get sent to the hospital the previous day as requested.During a surveyor interview on 3/25/2026 at 10:16 AM with the resident, s/he revealed that recently s/he had bad chest pain and asked to go to the hospital. Additionally, s/he revealed a nurse told him/her that s/he would not be transferred to the hospital.During a surveyor interview on 3/25/2026 at 1:26 PM with Registered Nurse, Staff A, she acknowledged that the resident complained of chest pain, requested to be transferred to the hospital and was not sent. Additionally, Staff A revealed that she did not notify the doctor of the resident's request to go to the hospital.During a surveyor interview on 3/25/2026 at 10:56 AM with the Director of Nursing Services she acknowledged that the resident was not sent to the hospital at his/her request. Additionally, she acknowledged that the resident's rights were not observed per the facility policy or the regulation.During a surveyor interview on 3/26/2026 at 9:45 AM with Physician, Staff B, he revealed that the resident should have been transferred to the hospital at his/her request.

Based on surveyor observation, record review, and staff interview, the facility failed to ensure that the food is stored, served, and distributed, in accordance with professional standards for food service safety, relative to the cleanliness of the dishes, the stove, and the flat top grill in the main kitchen.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 11/28/2025, alleges in part, the unsanitary state of the kitchen has caused death and sickness of many residents at the facility. Additionally, the complaint alleged that the kitchen floor is not mopped, the dishes, the silverware, the cups, and the coffee mugs are not cleaned properly, as they are often sent to the residents with food residue on them for each meal.Record review of an undated facility document titled MAINTENANCE OF SANITARY CONDITIONS, revealed in part, sanitary condition are maintained in the storage preparation and distribution of food. These conditions are maintained in accordance with federal and state regulations. Effective procedures for cleaning equipment and work areas are followed consistently.During a surveyor observation on 12/2/2025 at 9:28 AM of the main kitchen refrigerator with the Food Service Director (FSD), the following were observed: - Three undated trays of prepared lettuce - Four hot dogs in an undated, opened zip-lock bag - Two muffins in a container labeled 11/22/2025During an interview immediately following this observation, the FSD acknowledged that the lettuce trays should have been labeled, and that the muffins and hot dogs should have been discarded.2. The FDA Food Code 2022 4-201.11 states in part, .equipment and utensils shall be durable to retain their characteristic qualities .During a surveyor observation on 12/2/2025 at approximately 9:35 AM, of the main kitchen, with the FSD, the following was observed: - Seven coffee pitchers and two coffee carafes with visible built-up of black and brown residue inside - Fifty-one coffee cups with visible brown staining insideDuring the interview immediately following the observation, the FSD acknowledged these findings and stated that he would expect dietary aides to thoroughly wash the coffee cups, pitchers, and carafes after each use. 3. The FDA Food Code 2022 4-101.11 states in part, .multi-use food contact surfaces shall be finished to have a smooth, easily cleanable surface and resistant to scoring . During a surveyor observation on 12/2/2025 at 9:40 AM, of the main kitchen, with the FSD, the following was observed: - The flat-top grill covered with built-up black and brown residue - A build-up of greasy brown stains around the top grill - A white stain on the wall behind the grill - A build-up of dried black matter and accumulated food debris inside the stoveDuring the follow-up interview, the FSD acknowledged these observations and indicated that he would expect dietary aides to clean the grill and stove.4. During a surveyor observation on 12/2/2025 at 10:00 AM, of the main kitchen, with the FSD, the coffee machine was observed to have an accumulation of brown flakes on its top surface, and a build-up of black and brown matter on the table where it was located.During a surveyor interview immediately following the observation with the FSD, he acknowledged the above-mentioned observations. Additionally, he revealed that he would expect everyone in the kitchen to be responsible for the cleanliness of the equipment. During a surveyor interview on 12/2/2025 at approximately 12:30 PM, with the Administrator, she was unable to provide evidence that the main kitchen equipment was maintained in a sanitary condition. She further stated that she would have expected dietary staff to replace the soiled coffee cups with new ones and that she would expect the FSD to be responsible for identifying and addressing issues in the kitchen.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to promote wound healing for 1 of 4 residents reviewed who is at risk for skin breakdown, Resident ID #1, and for 1 of 2 residents reviewed with actual pressure ulcers (a localized injury to the skin and/or underlying skin usually over a bony prominence), Resident ID #2. Findings are as follows: 1. Record review revealed Resident ID #1 was admitted to the facility in May of 2025 with a diagnosis including, but not limited to, dependence on a ventilator (a device that assists in breathing). Record review of the facility's admission skin assessment dated [DATE] revealed the resident had an excoriation (an excoriation is a linear erosion caused by scratching, rubbing, or picking) to his/her sacrum. Record review of the physician's orders failed to reveal evidence of a treatment order for the resident's excoriated sacrum. Further record review revealed Resident ID #1 was transferred to the hospital on 5/17/2025 and was readmitted to the facility on [DATE]. Record review of the re-admission skin assessment dated [DATE] revealed s/he had an excoriated sacrum. Record review of a care plan dated 5/20/2025 revealed the resident is at risk for skin breakdown with interventions including, but not limited to, pressure areas and interventions are to be placed. Record review of the physician's orders failed to reveal evidence of a treatment order for the excoriated sacrum. Record review revealed the resident was transferred to the hospital on 5/22/2025. Record review of the hospital admission physician's progress note dated 5/22/2025 indicated that Resident ID #1 presented to the hospital with a Stage II (a shallow open ulcer with a red-pink wound bed) pressure injury to his/her sacrum. During a surveyor interview on 6/10/2025 at 2:43 PM with the admitting nurse, Registered Nurse, Staff A, she acknowledged that on 5/20/2025 the resident was re-admitted with an excoriated sacrum and that she did not obtain a treatment order for the area. During a surveyor interview on 6/10/2025 at 2:57 PM with the Director of Nursing Services (DNS), she acknowledged that there was no treatment order for the excoriated sacrum. Additionally, she revealed that upon admission to the facility, she would expect that the nurse would complete a skin assessment and obtain treatment orders for any skin impairments. 2. Record review revealed Resident ID #2 was admitted to the facility in June of 2025 with diagnoses including, but not limited to, pressure ulcer of the sacral region and diabetes mellitus. Record review of the facility's admission skin assessment dated [DATE] revealed the following: - A sacral stage II pressure ulcer - A left gluteal fold (located at the bottom border of the buttocks) stage II pressure ulcer - A right gluteal fold pressure ulcer - A right lateral (towards the side) gluteal fold pressure ulcer Record review of the physician's orders revealed the following wound treatment orders dated 6/6/2025: - Sacrum/bilateral buttocks, (the sacral, left gluteal fold, right gluteal fold and the right lateral gluteal fold pressure ulcers), cleanse with normal saline and apply zinc oxide-based paste to the wound bed and cover with bordered foam dressing daily. Additional record review of the sacrum/buttocks treatment order revealed that the order was entered into the computer system without being designated to the Treatment Administration Record (TAR), therefore the wound treatment order was not transcribed onto the TAR; therefore, the treatments for the sacral stage II pressure ulcer, left gluteal fold, right gluteal fold and the right lateral gluteal fold was not available for the staff to see and complete daily as ordered. During a surveyor interview with the DNS on 6/10/2025 at 4:20 PM, she was unable to provide evidence that the treatment was implemented for the above-mentioned wounds as ordered for Resident ID #2.

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 comprehensive care plan relative to 1 of 2 residents reviewed with non-pressure wounds, Resident ID #1. Findings are as follows: Record review revealed Resident ID #1 was admitted to the facility in May of 2025 with a diagnosis including, but not limited to, dependence on a ventilator (a device that assists in breathing). Record review of the admission skin assessment dated [DATE] revealed the resident had the following skin impairments: -A rash to the upper-mid vertebrae (an area of the spine) -An excoriation (the mechanical removal of the skins surface caused by scratching, rubbing, or picking) to his/her groin Record review of the physician's orders revealed an order dated 5/13/2025 for Miconazole Nitrate (a medicated powder prescribed to treat a fungal rash) to be applied to the groin twice daily. Additional review of the physician's orders failed to reveal evidence of a treatment order for the resident's rash to his/her vertebrae. Record review revealed the resident was transferred to the hospital on 5/17/2025 and was readmitted to the facility on [DATE]. Record review of the re-admission skin assessment dated [DATE] revealed the following skin impairments: - A rash to the vertebrae -An excoriation to the groin Record review of the physician's orders revealed an order dated 5/21/2025 for Miconazole Nitrate Powder 2%, to be applied to the groin twice daily. Additional review of the physician's orders failed to reveal evidence of a treatment order for the resident's rash to his/her vertebrae. Record review revealed the resident was transferred to the hospital on 5/22/2025 due to elevated blood pressure. Record review of the hospital admission paperwork dated 5/22/2025, revealed the resident complained about and was found to have a fungal rash to his/her back and a fungal infection to his/her groin and genital area. Additionally, the hospital paperwork indicated that the resident presented to the hospital after s/he was found to have a blood pressure of 240/120 (a normal blood pressure reading is 130/80) on the morning of 5/22/2025. Further review revealed documentation that indicated the cause of the resident's labile blood pressures (a condition where the blood pressure fluctuates significantly) was likely due to fungal infection. During a surveyor interview on 6/10/2025 at 2:43 PM with the admitting nurse, Registered Nurse, Staff A, she revealed that on 5/20/2025 Resident ID #1 was re-admitted with a reddened rash to his/her groin and his/her entire back. Additionally, Staff A revealed that the resident was readmitted from the hospital with a treatment order for his/her groin rash and Staff A did not obtain a treatment order for the rash that she identified on the resident's entire back. During a surveyor interview on 6/10/2025 at 2:57 PM with the Director of Nursing Services, she acknowledged that there were no treatment orders initiated for the rash that was identified on the resident's vertebrae when s/he was admitted to the facility on 5/12 and re-admitted on [DATE]. Additionally, she revealed that upon admission to the facility, she would expect that the nurse would complete a skin assessment and obtain orders for all areas requiring treatments.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from physical restraints that are not required to treat the resident's medical symptoms for 1 of 1 resident reviewed for an actual restraint, as the resident was observed in bed with a bed sheet tied across him/her, Resident ID #1. Findings are as follows: Review of a facility policy titled, Restraint Use-Physical states in part, .A physical restraint may be used only as a last resort and for a short period of time when it is documented in the medical record that the use of said restraint is in the best interests of the resident and allows the resident to receive the treatment that he/she has previously agreed to receive. Nursing documentation must specifically describe the behavior/medical symptoms that indicate the need for restraints and all the interventions that have been attempted before obtaining a doctor's order for a restraint . Record review of a facility reported incident submitted to the Rhode Island Department of Health on 2/27/2025 states in part, During first rounds on the day shift this morning, one of our CNAs [Certified Nursing Assistant] reported to the Director of Nursing (DNS) that one of the residents was found in bed with a bed sheet over [his/her] waist, seemingly placed this way to prevent [him/her] from getting out of bed; the bed sheet was loosely tied with each end tied to each (left and right) side rail . Record review revealed that the resident was admitted to the facility in February of 2025 with diagnoses including, but not limited to, epilepsy, cerebral infarction (stroke) and aphasia (a comprehension and communication disorder resulting from damage or injury to the brain). Review of a facility provided statement authored by CNA, Staff A, dated 2/27/2025 states in part, On the night of 2/26/25 at 8:00 PM I laid [Resident ID #1] in [his/her] bed and tied [him/her] from one side to the other on [his/her] stomach with a sheet, so [s/he] doesn't move or fall .I've seen [him/her] tied up in the past and I never reported it because I thought it was ok to do since [s/he] is a frequent faller. Review of a facility provided statement authored by CNA, Staff B, dated 2/27/2025 states in part, Today 2/27/25 me and [CNA, Staff C] went to get [Resident ID #1] washed for the day, while I was removing some of [his/her] blankets I notice [sic] a blanket was tied from each of the siderails restraining [him/her] to the bed . During a surveyor interview on 2/28/2025 at 1:02 PM with Staff B, she revealed that she found the resident in bed with a sheet tied from one side rail to the other. Additionally, Staff B revealed that the resident was found with pillows surrounding him/her. Per Staff B there were three pillows on each side of the resident, and they were tucked under the fitted sheet to keep them in place. Staff B revealed that the resident was unable to get out of bed due to the tied sheet and the pillows surrounding him/her. Review of a facility provided statement authored by Registered Nurse, Staff D, states, I [Staff D] have never restrained, restricted, nor tied said patient to a bed. Safety of a patient is a priority and due to recent multiple falls, impulsivity, and lack of proper staffing I have tucked patient in bed but in no way was it a restraint. During a surveyor interview on 3/3/2025 at 1:25 PM with CNA, Staff E, she revealed that she observed Staff D, roll up a flat sheet and place it across the resident's stomach, through the side rails and tuck it under the mattress. Additionally, Staff E revealed that when the sheet was across Resident ID #1 and tucked under the mattress s/he was unable to get up or roll over independently. Record review failed to reveal evidence of a physician order for a restraint, an assessment for the use of a restraint, medical symptoms being treated or interventions attempted prior to the use of a restraint. During a surveyor interview on 2/28/2025 at 11:53 AM with the Administrator and DNS, they acknowledged that Resident ID #1 was physically restrained on 2/26/2025 by Staff A. During a follow up interview on 3/3/2025 at approximately 12:00 PM with the Administrator she acknowledged that Staff D revealed she uses a flat sheet to tuck Resident ID #1 in bed to keep him/her from falling. Additionally, the Administrator acknowledged that tucking a sheet under the mattress to restrict the resident from getting out of bed is a physical restraint. This failure had the potential to cause more than minimal harm as the resident was at risk for entrapment, suffocation, strangulation injury or death.

Based on record review, staff and resident interview, it has been determined that the facility failed to keep a resident free from physical abuse for 1 of 7 residents reviewed, Resident ID #7. Findings are as follows: Review of a facility policy titled, Abuse Prohibition states in part, It is the policy of this facility to ensure that all residents are treated with respect and dignity and that all residents are free from abuse, mistreatment, neglect .Abuse: willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish . Review of a facility reported incident received by the Rhode Island Department of Health on 3/3/2025 revealed that the Administrator was informed that an Activity Aide was seen coming down the hall, wheeling Resident ID #7 very quickly and then let go of the wheelchair causing the resident to roll several more feet and hitting the wall. The resident was startled, but did not fall and was not injured. Record review revealed that Resident ID #7 was readmitted to the facility in 1/2025 with diagnoses including, but not limited to, dementia and anxiety disorder. Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 7 out of 15, indicating severe cognitive impairment. Additional review of the assessment revealed that s/he self-propels independently in his/her wheelchair. Review of a statement authored by Nursing Assistant (NA), Staff F, revealed that she witnessed Activity Aide, Staff G, wheeling the resident erratically and stated get out of here and aggressively pushed the resident's wheelchair and then let go. Per Staff F, the wheelchair continued to roll and hit the wall. During a surveyor interview on 3/3/2025 at 9:15 AM with the resident, s/he revealed that somebody pushed my wheelchair. Additionally, the resident revealed that s/he was unsure why this happened and was startled by the interaction. During a surveyor interview on 3/3/2025 at 9:31 AM with Staff G, she acknowledged that she did push the resident's wheelchair and it hit the wall. Additionally, she revealed that she made a mistake and knows that the resident has dementia and she should not get upset with him/her. Staff G indicated that the resident was shutting the lights off during an activity and that her own anxiety was heightened when she pushed the resident's wheelchair. During a surveyor interview on 3/3/2025 at approximately 8:00 AM with the Administrator, she acknowledged that Resident ID #7 was pushed aggressively by Staff G and that his/her wheelchair hit the wall. She revealed that the resident was immediately assessed and did not sustain any injury. Additionally, she revealed that the staff member was immediately suspended pending her completed investigation and that all staff received additional abuse training. The Administrator was unable to provide evidence that all residents were treated with respect and dignity and kept free from abuse.

Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to provide and prepare food in a form designed to meet individual needs for 3 of 4 residents reviewed with a physician's order for thickened consistency fluids, including mildly thick (nectar) and moderately thick (honey) consistencies, Resident ID #s 7, 26, and 98. Findings are as follows: 1. Record review revealed Resident ID #26 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, dysphagia, chronic obstructive pulmonary disease (COPD), and pneumonitis (inflammation of the lungs making it difficult to breathe) due to inhalation of food and vomit. Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. Review of the care plan revealed a focus area initiated on 11/7/2024 indicating Resident ID #26 has a potential for aspiration due to dysphagia with an intervention to provide a therapeutic diet as ordered including the prescribed fluid consistency. Review of a physician's diet order dated 11/6/2024 revealed that Resident ID #26 requires nectar thickened fluids. Record review revealed the following progress notes: - 11/3/2024: Resident ID #26 complained about being short of breath and his/her oxygen saturation level (spo2) dropped to 64% on 3 liters of oxygen (normal spo2 of an individual with COPD is typically 88-92%), his/her respirations were elevated at 32 respirations per minute (normal respirations per minute approximately 12-20 at rest), and his/her temperature was elevated to 99.6 degrees Fahrenheit (F) (normal body temperature approximately 98.6 degrees F). Additionally, s/he was transferred to the hospital via rescue. - 11/6/2024: Resident ID #26 returned from the hospital and was to continue receiving oral antibiotics and an anti-inflammatory medication for his/her COPD exacerbation and pneumonia. Review of a Speech Therapy document dated 11/8/2024 revealed that Resident ID #26 had a swallowing assessment completed at the hospital that revealed s/he has silent aspiration (no overt signs of choking) of thin liquids and poor clearance with coughing. Additionally, the resident's diet was modified to include nectar thick liquids. During a surveyor observation of Resident ID #26 on 11/18/2024 at approximately 12:10 PM, during the lunch meal revealed a lunch meal ticket dated 11/18/2024, that indicated s/he was to receive 4 oz. of nectar thick milk, 4 oz. of nectar thick cola, and 6 oz. of nectar thick coffee. Further observation revealed the resident had a 6 oz. cup of apple juice that was full, a 6 oz. cup of milk that was full, and an 8 oz. cup of coffee that was full on his/her meal tray. During a surveyor interview with NA, Staff A immediately following the above observation she revealed that the resident requires nectar consistency fluids and the nursing staff on the unit are responsible for preparing the beverages to the prescribed consistency. Additionally she revealed thickening packets provided by Dietary on the meal tray are used to thicken the beverages. Staff A further revealed that there was 1 thickening packet provided by dietary per beverage and that is what she used to prepare the nectar thick consistency beverages. Additionally, Staff A revealed that she does not read the instructions on the thickening packets nor does she premeasure the fluids that she pours into the cups on the tray. Lastly, after reviewing the instructions on the thickener packet with the surveyor, she acknowledged that the milk and apple juice require 1.5 thickening packets to achieve a nectar consistency, as the resident was served 6 oz. of these beverages and a single thickening packet is only sufficient for a 4 oz. serving, and the coffee requires 2 packets, as it is an 8 oz. serving. Review of the thickening packet used to thicken Resident ID #26's fluids, SimplyThick Easy Mix instant food thickener, Mildly Thick, Nectar Thick states, .Directions .Add to 4 fl. oz. of liquid . During a surveyor interview on 11/18/2024 at 12:19 PM with Licensed Practical Nurse, Staff M, she revealed that the nurses typically do not oversee the NAs thickening of the fluids for the residents. Additionally, she revealed that dietary sends the thickening packets on the residents' trays and indicated that 1 thickening packet per beverage is sufficient to achieve the desired consistency for all the prescribed thickened fluids. During a surveyor interview on 11/18/2024 at approximately 12:30 PM with the Food Service Director (FSD) in the presence of the Dietitian, he revealed that dietary places the thickening packets on the residents' trays and the nursing staff are responsible to thicken fluids on the units. The FSD indicated that dietary provides the exact amount of thickening packets on the residents' trays to achieve the prescribed consistency of fluids for the residents. Additionally, they acknowledged that the coffee/tea mugs held more than 8 oz. of fluid and the hard plastic cup that milk/juices are served in held more than 6 oz of fluid. During a surveyor interview on 11/18/2024 at approximately 1:00 PM with Dietary Aid, Staff D, she revealed that she was the individual that placed the thickening packets on the residents' trays for the lunch meal service on 11/18/2024. She further revealed that she places 1 thickening packet per beverage on the trays for residents who are prescribed thickened fluids. Additionally, she stated that she was unaware that some beverages required more than 1 thickening packet to achieve the prescribed consistency. Furthermore, she revealed that she has been working at the facility for approximately 4-5 months and has not received any training or education regarding thickening agents and modified consistency fluids. A surveyor interview was attempted with Resident ID #26's physician on 11/18/2024 at 1:12 PM, a voice message was left, however no return call has been received. During a surveyor interview on 11/18/2024 at approximately 2:30 PM with the Director of Nursing Services (DNS), she revealed that facility wide education is required for staff regarding the process of thickening fluids for the residents. Additionally, she revealed that she would expect that the nursing staff would be reading the instructions on the thickening packets and measuring the volume of fluids that they add to the cups and not just filling them up. During a surveyor interview on 11/19/2024 at approximately 10:00 AM with Resident ID #26, s/he indicated that s/he chokes and coughs when drinking the beverages that are prepared by the staff. 2. Record review revealed Resident ID #7 was admitted to the facility in March of 2023 with a diagnosis including, but not limited to, dysphagia (difficulty swallowing). Review of the care plan revealed a focus area last revised on 7/25/2023 indicating Resident ID #7 is at risk for an alteration in nutrition with an intervention to provide a therapeutic diet as ordered, including the prescribed fluid consistency. Review of a physician's diet order dated 5/28/2024 revealed that Resident ID #7 requires honey thickened fluids. Review of a Speech Therapy document dated 7/9/2024 revealed that Resident ID #7 indicated s/he feels like s/he chokes with thin liquids and s/he is recommended to continue with honey thickened fluids due to his/her physical impairments and functional deficits that place him/her at risk for aspiration, repeat pneumonia, and dehydration. Review of Resident ID #7's lunch meal ticket dated 11/18/2024 revealed s/he was to receive 4 ounces (oz) of honey thick milk and 6 oz. of honey thick coffee. During a surveyor observation and simultaneous interview on 11/18/2024 at approximately 12:30 PM of Resident ID #7's lunch meal with Nursing Assistant (NA), Staff B, and the Assistant Director of Nursing Services (ADNS), Resident ID #7 was observed to have a 4 oz. cup of cranberry juice that was half empty, a 6 oz. cup of milk that was full, and an 8 oz. cup of coffee that was full. Staff B revealed that she does not pre-measure the fluids prior to filling up the cups on the tray provided by the kitchen. Staff B further revealed that she uses only 1 packet of thickener to thicken each beverage and indicated that if she thickens it more, the resident will not drink the beverage. Review of the thickening packet used to thicken Resident ID #7's fluids during the above observation with the ADNS and Staff B, it revealed, SimplyThick Easy Mix instant food thickener, Moderately Thick, Honey Thick states, .Directions .Add to 4 fl. [fluid] oz. of liquid . Staff B stated that she only used one packet to thicken the resident's beverages and acknowledged that she should have used 2 packets to thicken the resident's coffee as it was 8 oz. to achieve the prescribed consistency. Additionally, the ADNS acknowledged that the cranberry juice, milk, and coffee were not honey consistency as prescribed. 3. Record review revealed Resident ID #98 was admitted to the facility in September of 2024 with diagnoses including, but not limited to, quadriplegia (paralysis that affects a person's limbs and body from the neck down) and dependence on a ventilator (a life support machine that helps people breathe when they are unable to do so on their own). Review of the care plan revealed a focus area last revised on 11/5/2024 indicating Resident ID #98 has aspiration pneumonia and receives oral nutrition in addition to his/her enteral nutrition (liquid nutrition provided via a gastrostomy tube [feeding tube]) with an intervention that includes to monitor for signs and symptoms of aspiration. Review of a physician's diet order dated 11/7/2024 revealed that Resident ID #98 requires nectar thickened fluids. Review of a Speech Therapy document dated 10/1/2024 revealed that Resident ID #98 is at risk for aspiration and pneumonia due to his/her physical impairments and functional deficits. During a surveyor observation and simultaneous interview on 11/18/2024 at approximately 11:45 AM of Resident ID #98's lunch meal, in the presence of Registered Nurse, Staff C, the resident was observed to have 1 cup of approximately 6 oz. of milk and 1 cup of approximately 8 oz. of coffee. Additionally, there were 2 unopened nectar thickening packets on the resident's tray. Staff C revealed that the resident had refused lunch, however if she were to prepare the thickened beverages for the resident to achieve nectar consistency, she would use 1 packet for the 6 oz. milk and 1 packet for the 8 oz. coffee. Review of the 2 thickening packets provided on Resident ID #98's tray, SimplyThick Easy Mix instant food thickener, Mildly Thick, Nectar Thick states, .Directions .Add to 4 fl. oz. of liquid . During a surveyor interview on 11/18/2024 at approximately 2:30 PM with the DNS, she was unable to provide evidence that the above residents were served a therapeutic diet and food in the appropriate form as prescribed by the physician. Additionally, she stated that she would expect the residents to receive fluids at the appropriate consistency as ordered, to ensure the safety of the residents. The facility's failure to provide and prepare foods in a form designed to meet individual needs for Resident ID #s 7, 26, and 98 placed the residents at risk for more than minimal harm, impairment, or death. 41729 46539

Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to assist residents in obtaining routine and emergency dental care for 1 of 1 resident reviewed, Resident ID #62. Findings are as follows: Record review revealed the resident was admitted to the facility in December of 2022 with diagnoses including, but not limited to, muscle weakness and legal blindness. Record review of a Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating s/he has intact cognition. During surveyor interviews with the resident on 11/18/2024 at 8:55 AM and 10:36 AM, s/he stated that s/he needs to have some teeth removed due to mouth pain. Additionally, s/he stated that s/he was supposed to be seen outside of the facility on two occasions however was not. Lastly, s/he revealed that s/he has a canker sore [a shallow, painful sore that develops on the soft tissue of the mouth] on his/her tongue because his/her tongue rubs against his/her teeth and causes him/her discomfort. Additionally, s/he indicated that the canker sore has been on his/her tongue for some time. During a surveyor observation of the resident's mouth and teeth on 11/18/2024 at approximately 9:00 AM, revealed that his/her teeth were dark, discolored, and jagged. His/her tongue was observed to have an approximately 1 centimeter abrasion that was surrounded by white tissue on the left side of his/her tongue. Further record review revealed documents containing mobile dentistry clinical notes which reveal the following: - On 5/23/2024, the note indicates that the resident is having a problem with teeth numbers 2 through 11, 13, 15, and 18 through 29 and s/he needs dental treatment that cannot be provided in the nursing facility. Additionally, the note indicates that the recommendation is for the resident to be seen by an oral surgeon for extractions due to broken and decayed teeth that irritate his/her tongue and is likely to cause him/her pain or infection. - On 8/27/2024, the note indicates that the facility was provided with a referral for oral surgery for his/her complaints of oral pain. - On 10/8/2024, the note indicates that the resident was seen for a broken tooth. Additionally, the document revealed that the resident has not had any teeth extractions yet and s/he requested to have teeth numbers 3 [upper right molar] and 19 [bottom left molar] to be extracted because they cut into his/her tongue. The document further indicates that a referral for oral surgery was sent to the facility on [DATE]. Record review of a progress note dated 11/11/2024 authored by the Unit Secretary, Staff R, revealed that the resident had an appointment at an outside dental clinic scheduled on 11/14/2024. Additional record review failed to reveal evidence that the resident was seen by the provider on 11/14/2024. Further record review of a progress note dated 11/15/2024 at 1:56 PM, authored by Registered Nurse (RN), Staff E, revealed that Resident ID #62 was scheduled to go out for an appointment but needed it to be rescheduled because the facility was unable to arrange transportation for the resident. During a surveyor telephone interview on 11/21/2024 at 9:12 AM with the dental office's receptionist she stated the following. Resident ID #62 had his/her first appointment as a new patient on 11/14/2024. S/he arrived at the appointment with a Nursing Assistant but did not have any identification or facility provided paperwork. The receptionist called the facility and was transferred several times with no resolution. She further stated that if she was able to speak with someone at the facility, she would have requested the resident's paperwork to be faxed over so s/he could be seen. The receptionist stated that she was able to reschedule the appointment emergently on the following day on 11/15/2024. She further revealed that on 11/15/2024, the resident never arrived at his/her appointment and no one from the facility called the office. The receptionist indicated that she called the facility and was told his/her ride did not show up. During a surveyor observation and interview with Resident ID #62 in the presence of Staff E, on 11/20/2024 at approximately 10:36 AM, she acknowledged the approximately 1 cm canker sore to the resident's left tongue. Resident ID #62 stated it has been there for some time. Further record review failed to reveal evidence of documentation indicating the resident had a canker sore or a treatment in place until it was brought to the attention of the facility by the surveyor. Record review revealed a progress note dated 11/20/2024 at 1:05 PM, authored by RN, Staff E, which indicates the provider was notified of the canker sore to the left side of the resident's tongue and s/he was ordered antiviral medication to be administered every 12 hours for 7 days. Additionally, topical oral pain medication was ordered to be applied to the affected area three times per day for 7 days. During a surveyor interview on 11/20/2024 at 2:43 PM with Staff R and the Administrator, revealed that Resident ID #62 went to dental appointment on 11/14/2024 however s/he was not seen because s/he did not go with the paperwork that s/he should have gone with. Additionally, Staff R indicated that an appointment was made for him/her to return on 11/15/2024, however, because of an issue with transportation s/he did not go. Lastly, the Administrator acknowledged that the facility has a vehicle and indicated that she did not offer transportation accommodations to the resident on 11/15/2024 after s/he had the second appointment to address his/her ongoing tooth and mouth pain. During a surveyor interview on 11/21/2024 at 11:01 AM with Director of Nursing Services (DNS), she stated that she would have expected that Resident ID #62 would have been provided with paperwork to take with him/her to the dental appointment on 11/14/2024. Additionally, she was unable to provide evidence that Resident ID #62 received dental services outside of the facility as recommended to address his/her ongoing dental pain.

Based on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 2 residents reviewed with a suprapubic catheter (SP catheter- a device inserted through the abdomen into the bladder to drain urine), Resident ID #16. Findings are as follows: 1a) Review of the facility's policy titled, Foley Catheters dated 1/16/2024 states in part, .3. The catheter is to be changed per MD [Medical Doctor] order . Record review revealed Resident ID #16 was admitted to the facility in August of 2023 with a diagnosis including, but not limited to, obstructive and reflux uropathy (a condition in which the flow of urine is blocked). Record review of a care plan dated 7/5/2024 revealed the resident has a SP catheter due to obstructive uropathy and staff interventions include, but are not limited to, change the resident's catheter per the facility's policy. Record review failed to reveal evidence that an order was obtained from the provider for the SP catheter to be changed while at the facility. Record review failed to reveal evidence that the SP catheter was changed from 5/13/2024 until 10/19/2024, a total of 20 weeks, missing 3 of 3 opportunities. Record review revealed the following progress notes related to the resident's catheter: - On 10/11/2024 at 3:00 PM: .resident pant was wet during care, minimal blood noted in catheter bag .findings reported to incoming nurse . - On 10/12/2024 at 1:38 AM: .Suprapubic Catheter Issue .Patient began to feel extreme pain unable to withdraw amount .pt.[patient] states painful .hematuria [blood in urine] complaint of 9/10 pain .condition is worsening . - On 10/12/2024 at 3:28 AM: Pt having trouble urinating, flushed with pink return called third eye [telehealth provider] .patient complaining of a lot of pain was instructed to send out via ambulance . - On 10/12/2024 at 3:30 AM: Pt. sent to [local hospital] due to suprapubic tube to be replaced .Pt complaining of an increase pain . - On 10/13/2024 at 9:42 AM: Resident transported back to the facility .offers c/o [complain of] suprapubic pain, foley [SP catheter] flushed, hematuria noted in urinary bag. Resident needs f/u [follow up] with urology for foley replacement, message left with unit secretary . - On 10/17/2024 at 7:01 AM: .patient returned from [acute care hospital] .patient started on ABX [antibiotic] for 7 days .suspected UTI [urinary tract infection] . - On 10/17/2024 at 2:55 PM: Resident noted to be very restless today .Resident noted to have hematuria, SPT [suprapubic tube] was also noted to be leaking .attempted to change SPT however resistance was noted .resident sent to ER [emergency room ] . - On 10/19/2024 at 2:42 PM: .Resident's SPT was noted leaking a large amount of urine on the floor .SPT was removed and replaced .continue on treatment for UTI . During a surveyor interview on 11/20/2024 at 8:29 AM with the resident, s/he indicated that his/her catheter was last changed sometime in May and could not recall a specific date. Additionally, the resident indicated that s/he has had discomfort and pain with the catheter. During a surveyor interview on 11/20/2024 at 8:32 AM, with a Licensed Practical Nurse, Staff M, she indicated that the resident had been sent to the hospital due to his/her catheter malfunctioning. Staff M further acknowledged that the resident did not have an order to change his/her catheter. During a surveyor interview on 11/20/2024 at 8:54 AM with the Medical Director (MD) who is also the resident's primary care physician, he indicated that he was not aware that an SP catheter could be changed at the facility until it was brought to his attention by the Assistant Director of Nursing a few weeks ago. The MD indicated that he would have expected the staff to have obtained an order to change the resident's catheter from the resident's urologist. Additionally, the MD indicated that he would expect the staff to notify the urologist whenever the resident is experiencing complications from his/her catheter. Record review revealed an order was written on 11/20/2024 at 9:56 AM to change the resident's SP catheter every 6 weeks. This order was obtained after it was brought to the facility's attention by the surveyor on 11/20/2024 at approximately 8:30 AM. 1b) Review of the facility's policy titled, Foley Catheters dated 1/16/2024 states in part, .8. If the resident is being followed by a urologist, ensure appointments are kept and followed . Record review of a care plan dated 7/5/2024 revealed the resident has a SP catheter due to obstructive uropathy and staff interventions include, but are not limited to, urology follow up as ordered and indicated. Review of a progress note dated 10/13/2024 revealed, Resident needs f/u [follow up] with urology for foley [SP] replacement, message left with unit secretary . Record review failed to reveal evidence that a urologist appointment was obtained as indicated in a progress note dated 10/13/2024 after the resident had returned from the hospital with an indication to follow up with his/her urologist. Additional record review failed to reveal evidence that the resident has had an appointment with his/her urologist since his/her admission in August 2023, until it was brought to the facility's attention by the surveyor on 11/20/2024. During a surveyor interview on 11/20/2024 at 8:54 AM with the Medical Director he indicated that he would expect the staff to notify the urologist whenever the resident is experiencing complications from his/her catheter. During a surveyor interview on 11/20/2024 at 9:24 AM with the secretary at the resident's urologist office, she indicated that the resident had an appointment scheduled for July 24, 2024. The office staff further indicated that the resident did not attend this appointment, and the urologist office did not receive a call from the facility to reschedule an appointment until on 11/20/2024 at approximately 9:00 AM. The staff at the urologist office further indicated that their records did not have any notification from the facility indicating the resident was experiencing complications from the catheter. During surveyor interviews on 11/20/2024 at 8:42 AM and 11:00 AM with the Director of Nursing Services (DNS), she indicated that the resident has had pain, discomfort, and malfunctioning of his/her SP catheter and has been sent to the hospital twice in October 2024 due to these symptoms. The DNS acknowledged that the resident's catheter was not changed at the hospital during these visits. She further acknowledged that the resident did not have a current order to change his/her catheter since it was last changed at the facility in May of 2024, and would expect the staff to have obtained an order from the physician. The DNS acknowledged that resident's catheter had not been changed since 5/13/2024, until she changed it on 10/19/2024 due to the resident experiencing pain and leakage at the catheter site. Additionally, the DNS acknowledged that the resident had an appointment with his/her urologist in July 2024 and was unable to explain why the resident did not attend this appointment or why the appointment was not rescheduled until it was brought to the facility's attention by the surveyor on 11/20/2024.

47279 Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety relative to 1 of 1 resident reviewed for safe food temperatures, Resident ID #45, and 3 of 3 ice machines without an air gap (gap between the water supply inlet and the flood level rim of the plumbing fixture). Findings are as follows: 1. The Rhode Island Food Code 2018 Edition 3.501.16, states in part, Time/Temperature Control for Safety Food Hot and Cold Holding .shall be maintained at .5 degrees C [Centigrade, which is 41 degrees Fahrenheit [F]] or less . Record review revealed that Resident ID #45 was readmitted to the facility in August of 2024 with diagnoses including, but not limited to, stroke and dysphagia (difficulty swallowing). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 2 out of 15 indicating severe cognitive impairment. Additional review of the MDS revealed that the resident requires extensive assistance of one staff member for eating. During a surveyor observation on 11/18/2024 at approximately 12:05 PM revealed a lunch tray was passed to the resident while s/he was sleeping in his/her chair. No staff was observed to be assisting the resident. During a surveyor observation on 11/18/2024 at 12:41 PM revealed a lunch tray sitting in front of Resident ID #45 while s/he slept. The tray contained half of a ham salad sandwich, mashed potatoes with gravy and approximately a 6-ounce glass of milk. No staff was observed to be assisting the resident. During a surveyor observation on 11/18/2024 at 1:06 PM revealed his/her lunch tray remained in front of him/her while s/he slept in his/her chair. During a surveyor interview on 11/18/2024 at 1:06 PM with Nursing Assistant (NA), Staff S, she revealed that residents will be woken up to eat, however, if the resident does not wake up then the staff will place the tray in the fridge. During a surveyor observation on 11/18/2024 at 1:08 PM of the resident revealed Staff S attempting to wake up the resident and offering him/her assistance to eat the ham salad sandwich that had been sitting in front of him/her for over an hour. Staff S acknowledged that the lunch tray had been sitting in front of the resident for longer than an hour. At this time the surveyor intervened to stop Staff S from feeding the resident the food on the tray. A surveyor interview was attempted with the resident on 11/18/2024 at approximately 1:10 PM, however s/he did not answer any questions asked by the surveyor. During a surveyor observation on 11/18/2024 at approximately 1:20 PM in the presence of Staff S, the temperature of the ham salad sandwich was obtained and registered at 66.6 degrees F. Additionally, the temperature of the milk was obtained and registered at 63.7 degrees F, both food items registered more than 20 degrees higher than the safe holding temperature of 41 degrees F. During a surveyor interview on 11/18/2024 at 1:30 PM with the Assistant Director of Nursing Services, she revealed that she would expect staff to wake up a resident to eat when the food is served or to store the food in the refrigerator until the resident is ready to eat it. During a surveyor interview on 11/18/2024 at 2:46 PM with the Food Service Director (FSD), he revealed that the ham salad sandwich and milk should remain at or below 41 degrees F to ensure food safety. During a surveyor interview on 11/18/2024 at 2:09 PM with the Administrator, she revealed that she would expect that the staff would not serve potentially hazardous foods to residents outside of the safe temperature. 2. Review of the Rhode Island Food Code 2018 Edition 5-202.13 states in part, An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or nonFOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25mm [millimeter] (1 inch). During a surveyor observation on 11/17/2024 at 9:44 AM in the presence of the FSD of the first floor kitchenette, revealed an ice machine without an air gap. Additionally, the pipe had a build up of black matter on the exterior of the pipe. During a surveyor observation on 11/17/2024 at 9:47 AM in the presence of the FSD of the second floor kitchenette, revealed an ice machine without an air gap. During a surveyor observation on 11/17/2024 at 9:51 AM in the presence of the FSD in the main kitchen, revealed an ice machine without an air gap. During a surveyor interview directly following the above observations with the FSD he acknowledged that all three of the facility's ice machines did not have an air gap as outlined in the Rhode Island Food Code. Additionally, he acknowledged the build up of black matter on the exterior of the pipe on the ice machine of the first floor kitchenette.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents with pressure ulcers receive the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 4 residents reviewed for pressure ulcers, Resident ID #s 65 and 84. Findings are as follows: 1. Review of a facility policy titled, Clean Dressing Technique dated January of 2018 states in part, .Check the physician order for current, correct treatment . Record review revealed that Resident ID #65 was readmitted to the facility in October of 2024 with diagnoses including, but not limited to, paraplegia (paralysis affecting the lower half of the body) and dependence on a ventilator (a life support machine that helps people breathe when they are unable to do so on their own). Review of an Integrated Wound Care follow up progress note dated 11/4/2024 revealed that the resident has a stage 4 pressure ulcer (most serious type of pressure ulcer that may impact muscle, tendons, ligaments, and bone) to his/her sacrum (base of the spine) measuring 3.5 centimeters (cm) by 8.5 cm by 0.1 cm. Further review revealed that s/he has a stage 4 pressure ulcer to his/her right ischium (a bone that forms the lower/back part of the hip) measuring 3.0 cm by 1.4 cm by 0.1 cm. Record review revealed physician's orders dated 11/18/2024 to cleanse both wounds with wound cleanser, pat dry, apply medihoney (a wound gel made from honey) to wound base, cover with calcium alginate AG (a wound treatment with silver; silver aides in preventing infection), and cover with a bordered foam dressing daily and as needed. During a surveyor observation on 11/20/2024 at approximately 12:15 PM of Resident ID #65's wound dressing changes, Registered Nurse (RN), Staff G, was observed applying calcium alginate to both wounds, instead of calcium alginate AG, which was ordered. During a surveyor interview on 11/20/2024 at 12:30 PM with Staff G, he acknowledged that he applied the incorrect dressing to the wounds. During a surveyor interview on 11/20/2024 at 1:20 PM with the Director of Nursing Services (DNS), she acknowledged that Staff G did not follow the physician's orders for calcium alginate AG for both of the wounds. 2. Review of a facility policy titled, Skin Care Protocol dated 1/6/2011 states in part, .With each dressing or at least weekly, the following documentation must be present: Location and staging; size, depth, and the presence, location and extent if any undermining or tunneling/sinus tract; exudate [drainage], if present; type, color, odor, and approximate amount; pain if present .wound bed: color, type of tissue/character including evidence of healing .description of wound edges and surrounding tissue . Record review revealed that Resident ID #84 was readmitted to the facility in February of 2024 with diagnoses including, but not limited to, stroke and muscle weakness. During a surveyor observation on 11/17/2024 at 9:15 AM revealed the resident was in bed and had a dressing in place to his/her second toe of the right foot. Record review revealed that Resident ID #84 has a wound to his/her right foot second toe that requires a daily dressing since 11/12/2024. Review of a progress note dated 11/18/2024 authored by Nurse Practitioner (NP), Staff H, revealed that she was conducting a follow up visit for Resident ID #84's wound on his/her right second toe. Additionally, the note revealed that a small open area with bloody drainage on the resident's right second toe was identified on 11/11/2024 and s/he was treated for cellulitis (a potentially serious bacterial skin infection) of the area with antibiotics for 7 days. Record review failed to reveal evidence of documentation of Resident ID #84's right second toe wound including, staging of the wound, measurements, and presence of pain, until after it was brought to the facility's attention by the surveyor. During a surveyor interview on 11/20/2024 at 8:20 AM with RN, Staff I, she acknowledged that Resident ID #84 has a wound to his/her right second toe. Additionally, she revealed that the wound was identified on 11/11/2024 and acknowledged that there were no wound measurements, staging, or descriptions of the wound documented since it was first identified on 11/11/2024. Review of a progress note dated 11/20/2024 at 8:49 AM indicated that the wound was measured at 0.3 cm by 0.2 cm by <0.1 cm after it was brought to the facility's attention by the surveyor. During a surveyor interview on 11/20/2024 at 9:25 AM with the Wound Nurse, RN, Staff J, she revealed that the there were no wound measurements or descriptions of the wound until it was brought to the facility's attention by the surveyor 9 days after the wound was identified. During a surveyor interview on 11/20/2024 at 11:26 AM with the DNS, she was unable to provide evidence of wound measurements or descriptions of Resident ID #84's wound.

Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ensure that the residents receive proper foot care and treatment in accordance with professional standards of practice for 1 of 1 resident reviewed, Resident ID #29. Findings are as follows: Record review revealed that the resident was admitted to the facility in March of 2024 with a diagnosis including, but not limited to, diabetes. Record review of a Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 out of 15, indicating intact cognition. During a surveyor interview on 11/17/2024 at 9:38 AM with the resident, s/he stated that s/he has not been offered or provided with podiatry services and would like to receive it. Record review revealed a physician's order dated 3/27/2024 for podiatry services as needed. Further record review failed to reveal evidence that podiatry services were offered or provided to the resident since his/her admission to the facility. During a surveyor observation of Resident ID #29's feet in the presence of Nursing Assistants (NA) Staff K and Staff L, on 11/20/2024 at 10:10 AM, revealed the skin of his/her feet had dry skin and long toenails. The great toenails extended approximately 1 inch above the toes and the remaining toenails were observed to be curved over touching the skin of the resident's toes. Staff K and L acknowledged the above observations. During a surveyor interview with Registered Nurse (RN) Staff E, on 11/20/2024 at 10:15 AM, she stated that the resident has not received podiatry services and was unable to say if s/he was offered it. During a surveyor observation of the resident's toes in the presence of RN, Staff E, on 11/20/2024 at 10:17 AM, she acknowledged that Resident ID # 29's feet had dry skin and long toenails. During a surveyor interview with the Administrator on 11/20/2024 at 2:41 PM, she was unable to provide evidence that Resident ID #29 was offered or provided with podiatry services since his/her admission to the facility.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store drugs and biologicals in accordance with currently accepted professional principles relative to 5 of 6 medication carts observed. Findings are as follows: Review of the facility's policy titled Medication storage states in part, .Procedures 2. Controlled medications must be stored separately from non-controlled medications. The access system (key, security codes) used to lock Schedule II medications [medications that have a high potential for abuse and may lead to severe physical or psychological dependence] and other medications subject to abuse, cannot be the same access system used to obtain the non-scheduled mediations .14. Outdated, contaminated, discontinued, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock . 1. During a surveyor observation on 11/17/2024 at 9:46 AM in the presence of Licensed Practical Nurse, Staff O, of the Meadows and Garden medication cart revealed the following: - Nitroglycerin sublingual tablets (a medication used to treat chest pain) without a resident identifier and with a manufacturer's expiration date of 10/23/2022 - Nitroglycerin sublingual tablets without a resident identifier and with a manufacturer's expiration date of 1/24 - Permethrin cream 5% topical (a medication used to treat scabies) one time use packet, opened, and dated 9/27/2024. - Ammonium Lactate 12% cream (a medication used to treat dry, scaly skin), open, not dated, and without a resident identifier. During a surveyor interview at the time of this observation with Staff O, she acknowledged the Nitroglycerin tablets and above-mentioned creams were expired and should have been discarded. 2. During a surveyor observation on 11/17/2024 at 10:51 AM in the presence of a Registered Nurse, Staff I, of the Pine nurse medication cart revealed a bottle of probiotic tablets (a medication used to promote gut health) with a manufacturer's expiration date of 9/2024. During a surveyor interview at the time of this observation with Staff I, she acknowledged the probiotic tablets were expired and should have been discarded. 3. During a surveyor observation on 11/17/2024 at 10:55 AM in the presence of a Certified Medication Technician (CMT), Staff P of the Vineyard medication cart revealed the following: - Twenty-two blue capsules observed in a clear plastic cup with no identifying information - Breo Ellipta 100 microgram (mcg)/25 mcg inhaler opened and not dated. Manufacturer's instruction indicates to discard the inhaler 6 weeks after opening. - Wixela 500/50 mcg inhaler opened and not dated. Manufacturer's instruction indicates to discard the inhaler 6 weeks after opening. - Trelegy Ellipta 20 mcg/62.5/25 mcg inhaler opened and not dated. Manufacturer's instruction indicates to discard the inhaler 6 weeks after opening. - One of one bottle of Active liquid protein opened and not dated. Manufacturer's instruction indicates to discard 3 months after opening. - One of one bottle of Geri-lanta regular strength antacid (a medication used to treat heartburn, upset stomach and acid indigestion) with a manufacturer's expiration date of 10/24. During a surveyor interview at the time of this observation with Staff P, she acknowledged the 22 capsules were not stored in a pharmacy or manufacturer's labeled container, indicating the name of the medication and a resident identifier. Additionally, Staff P acknowledged the inhalers and the bottle of liquid protein were opened and not dated, and the antacid was expired. 4. During a surveyor observation on 11/17/2024 at 11:00 AM in the presence of a Registered Nurse, Staff Q, of the [NAME] low side medication cart revealed the following: - Ibuprofen oral liquid suspension (pain medication) with a use by date of 1/31/2024. - EpiPen injection (a medication used to treat a life-threatening allergic reaction in an emergency) with a manufacturer's expiration date of 7/2024. - Refresh Lacri-lube eye ointment, opened and not dated. Manufacturer's instruction indicates to discard 30 days after opening. - Docusate sodium liquid (stool softener), opened, not dated, and the manufacturer's expiration date was not legible. - Mucus relief 400 milligram (mg, a medication used to treat cough) with a manufacturer's expiration date of 9/2024. - Oyster shell calcium 500 mg (supplement) with a manufacturer's expiration date of 8/2024. - Ultra lubricant eye drops with an open date of 12/15/2023. Manufacturer's instruction indicates to discard the eye drops one month after opening. - Gas relief 80 mg tablets with a manufacturer's expiration date of 8/2024. - Bisacodyl 5 mg tablets (a medication used to treat constipation) with a manufacturer's expiration date of 9/2024. - Magnesium chloride with calcium (supplement) with a manufacturer's expiration date of 6/2024. - One-daily multivitamin tablets with a manufacturer's expiration date of 8/2024. - Calcium 600 +D mcg tablets (supplement with vitamin D) with a manufacturer's expiration date of 6/2024. - Active liquid protein opened and not dated. Manufacturer's instruction indicates to discard 3 months after opening. During a surveyor interview at the time of this observation with Staff Q, she acknowledged the above-mentioned medications were expired and should have been discarded. 5. During a surveyor observation on 11/17/2024 at 11:19 AM in the presence of a Registered Nurse, Staff M of the garden CMT medication cart revealed a bottle of Roxanol (a schedule II pain medication) that was not stored in a double locked compartment of the medication cart. During a surveyor interview at the time of this observation with Staff M, she acknowledged the Roxanol should have been stored in the narcotic box in the nurse's medication cart and not the CMT cart as observed. During a surveyor interview on 11/19/2024 at 10:02 AM with the Director of Nursing Services (DNS), she indicated that she would expect the staff to audit the medication carts at least once a week and all expired medications should be discarded. The DNS further indicated that she would expect the Roxanol to be stored in a double locked compartment of the nurse's medication cart and not stored in the single locked CMT cart, as observed. Additionally, the DNS indicated that she would expect the staff to appropriately date all eye drops and inhalers upon opening, as per the manufacturer's instructions. 46539 46715 47279

Based on record review and staff interview it has been determined that the facility failed to ensure residents maintain acceptable parameters of nutritional status such a usual body weight or desirable body weight and are offered sufficient fluid intake to maintain proper hydration for 3 of 7 residents reviewed, Resident ID #s 81, 202 and 304. Additionally, the facility failed to offer a therapeutic diet when there is a nutritional problem for 1 of 7 residents reviewed, Resident ID #303. Findings are as follows: 1.According to the Standard Nursing Practice second edition, 2003 .dry mucus membranes are signs of dehydration. Intake and output needs to be monitored to determine body fluid status. According to Elsevier, 2024, .dehydration occurs when an individual excretes too much water without also excreting electrolytes .Diarrhea and vomiting are common causes of dehydration due to rapid fluid loss through the gastrointestinal tract .signs and symptoms .an individual may experience fatigue, dark urine, less frequent urination, dry skin, or dry lips. In addition to these, as severity increases .in severe situations, an individual may experience .death .Blood test results that suggest hypertonic dehydration include elevated blood urea nitrogen (BUN)[In dehydration, as water decreases and urea is reabsorbed, the BUN rises.] .elevated sodium (Na) .Individuals with severe dehydration who do not respond to oral rehydration therapy may need to be administered fluids via IV [Intravenously]. Review of the facility's diet manual Diet & Dining Manual for Extended Care in a Culture changes Environment from section Fluid Management 2019, states in part, While the fluid intake goals need to be calculated and individualized by the Registered Dietitian, generally the elderly population should take in a minimum of 1500 [milliliters] per day .and preferably up to 2000 [milliliters] per day . 1. Record review revealed Resident ID #202 was admitted to the facility in December of 2023 with diagnoses including, but not limited to, below the knee amputation aftercare, infection in the surgical wound, and a history of congestive heart failure (a weakness of the heart that leads to the buildup of fluid in the lungs and the surrounding tissue). Record review revealed the following inadequate oral fluid intakes for the resident: -[DATE]- 580 ml -[DATE]- 840 ml -[DATE]- 0 ml -[DATE]- 1,080 ml -[DATE]- 960 ml -[DATE]- 480 ml -[DATE]- 600 ml [DATE]- none documented [DATE]- 120 ml [DATE]- 720 ml [DATE]- 0 ml Record review revealed documentation of diarrhea on the following days: -[DATE]- twice -[DATE]- three times -[DATE]- once -[DATE]- twice -[DATE]- once Record review revealed a progress note dated [DATE], authored by Nurse Practitioner (NP) Staff A, which states in part, Diarrhea .Imodium [Loperamide] PRN [as needed] diarrhea . Further review revealed the resident's mouth was dry on assessment and to encourage fluids. Record review failed to reveal evidence that the resident received his/her ordered dose of Imodium when s/he experienced episode(s) of diarrhea on [DATE], [DATE], [DATE], [DATE] and [DATE]. Record review revealed the following lab values that may be indicative of dehydration: -[DATE]= Na (level of 146 milliequivalents per liter (mEq/L; normal lab value ,d+[DATE] mEq/L) = 146, BUN (Blood Urea Nitrogen- an indicator of kidney function) of 31 milligrams per deciliter, (MG/DL; normal lab value ,d+[DATE] MG/DL) = 31 -[DATE]- Na= 150, BUN= 32 -[DATE]- Na=148, BUN=29 -[DATE]- Na=148, BUN= 32 - [DATE]- Na= 152, BUN= 43 Record review revealed the resident had a foley catheter in place for urinary retention. Further record review failed to reveal evidence that the resident's urine output was being documented or monitored when the facility had documented evidence that the resident had poor oral fluid intake, was experiencing diarrhea and had abnormal lab values that could indicate the resident was dehydrated. Record review revealed the resident was administered IV fluids on [DATE] for hydration. Record review revealed the resident expired at the facility on [DATE] at 10:38 AM. Record review indicated that the resident was suffering from dehydration prior to his/her death at the facility as evidenced by multiple days of a poor oral fluid intake, fluid loss through diarrhea, abnormal lab values that are indicative of dehydration, and the need for IV fluids for hydration given on [DATE], the evening prior to his/her death on the morning of [DATE]. During a surveyor interview on [DATE] at 12:06 PM with Registered Nurse, Staff B, she could not provide evidence that an intervention was implemented for the resident's diarrhea. During a surveyor interview on [DATE] at 9:46 AM with Nurse Practitioner, Staff A, she indicated that the resident was lethargic and confused at times during his/her admission as well as experiencing diarrhea. She further indicated that the resident's Na and BUN levels were elevated and that the resident may have been dehydrated due to the loose stools. During a surveyor interview on [DATE] at 10:45 AM with the Director of Nursing Services (DNS), she indicated that she would expect that the urine output for Resident ID #202 to be monitored and documented. Additionally, she could not provide evidence that the facility properly maintained the resident's hydration. Refer to F 658 2a. Review of a facility policy titled, Weight Loss/Gain Protocol dated ,d+[DATE] states in part, .For the purpose of this policy, a significant weight discrepancy is defined as: 1. Daily weights- a change of 3 pounds or more in a day, or a weight change of 5 pounds in one week. 2. Monthly weights- a loss/gain of 5% within one month .When a significant weight loss or gain is noted (as defined above), the following interventions must occur .a reweigh will be completed within 48 hours for a resident with a significant weight discrepancy. 3. If the re-weigh is accurate and there has been a significant weight gain/loss, the following must be notified: a Physician b. Dietician c. Family/responsible party . Record review revealed that Resident ID #81 was admitted to the facility in April of 2023 with diagnoses including, but not limited to, dementia and feeding difficulty. Record review of the resident's documented weights revealed the following: -[DATE] 153.4 pounds (Lbs.) -[DATE] 151.6 Lbs. -[DATE] 149.2 Lbs. -[DATE] 147.0 Lbs. -[DATE] 143.4 Lbs. Review of a progress note authored by the Registered Dietitian on [DATE] revealed that the resident had a weight loss, and a recommendation was made for Mighty Shakes (a supplement used to prevent weight loss), three times a day, as an intervention. Review of the physician's orders failed to reveal evidence that the recommendation for Mighty Shakes, three times a day, was implemented to prevent further weight loss. Further review of the resident's documented weights revealed the resident continued to lose weight after the weight loss was identified on [DATE], without an added intervention in place, for a total of a 5.8 Lbs. weight loss in 2 months. During a surveyor interview on [DATE] at 9:33 AM with Registered Nurse (RN), Staff B, she acknowledged that the recommendation for Mighty Shakes was not implemented and revealed that she would have expected the recommendation to be implemented and to be transcribed into the physician's orders. During a surveyor interview on [DATE] at 10:00 AM with the Registered Dietitian, she revealed that she would have expected the Mighty Shakes to have been put in to place after her recommendation, to prevent further weight loss. Additionally, she revealed that she had missed a step with this recommendation and failed to put it in the electronic communication for the nurses to forward to the resident's physician for approval. During a surveyor interview on [DATE] at 12:37 PM with the Director of Nursing Services (DNS), she revealed that she would expect the recommendation for the Mighty Shakes to be implemented to prevent future weight loss. Additionally, she was unable to provide evidence that the resident's Mighty Shakes were implemented to maintain acceptable parameters of nutritional status related to weight loss and acknowledged that the resident continued to lose weight. 2b. Review of Resident ID #81's care plan revealed that s/he is at risk for weight loss, dehydration, and malnutrition related to dementia and type 2 diabetes. It further revealed interventions which include, but are not limited to, encourage adequate fluid intake and to monitor and record food and fluid intake. Review of a progress note dated [DATE], authored by the Registered Dietitian, states in part, .Estimated fluid needs 2000 [mL] . Review of the resident's documented fluid intake from [DATE] through [DATE] failed to revealed evidence that the resident's fluid intake met the recommended estimated fluid intake needs. Further review revealed the resident's fluid intake was less than 1000 mL on the following dates: -[DATE] 480 mL -[DATE] 740 mL -[DATE] 840 mL -[DATE] 840 mL -[DATE] 360 mL -[DATE] 240 mL -[DATE] 600 mL -[DATE] 720 mL During a surveyor interview on [DATE] at 10:00 AM with the Registered Dietitian, she acknowledged that the resident's fluid intake documentation did not meet the resident's estimated recommended fluid intake. During a surveyor interview on [DATE] at 12:37 PM with the DNS, she acknowledged that the documented fluid intake was less than the 1500 ml per the diet manual daily or the estimated fluid consumption of 2000 mL, per the Registered Dietitian's calculations. 3a. According to the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities last revised on [DATE] reveals in part, suggested parameters for evaluating significance of unplanned and undesired weight loss in 1 month are, significant weight loss is 5% weight loss in a month and severe weight loss is greater than 5% weight loss in one month. Record review revealed that Resident ID #304 was admitted to the facility in December of 2023 with diagnoses including, but not limited to, Barrett's esophagus (a condition in which the lining of the swallowing tube that connects the mouth to the stomach becomes damaged by acid reflux) without dysplasia (abnormal growth) and dysphagia (difficulty swallowing). Record review of the resident's documented weights revealed the following: -[DATE]- 204.12 Lbs. -[DATE]- 202.0 Lbs. -[DATE]- 188.7 Lbs.- a 13.3 Lbs. weight loss, 6.58% weight loss in a week indicating severe weight loss -[DATE]- 188.2 Lbs.- a 13.8 Lbs. weight loss, 6.83% weight loss in a week indicating severe weight loss Review of the resident's progress notes from [DATE] through [DATE] failed to reveal evidence the Physician, Dietician or family/responsible party were notified of the approximate 13 Lbs. weight loss in one week. During a surveyor interview on [DATE] at 9:53 AM with the Registered Dietitian, she revealed that she was not notified of the resident's weight loss. She further revealed that she will assess him/her today, after the weight loss was brought to her attention by the surveyor. During a surveyor interview on [DATE] at 10:04 AM, with RN, Staff D, she revealed that the facility has a Nurse Practitioner (NP), Staff A, in the building 5 days a week and that they would notify her of any weight changes. She further revealed that she was unsure if the NP was notified of the resident's weight loss. During a surveyor interview with NP, Staff A, on [DATE] at 10:28 AM, she revealed that she was unaware of the resident's weight loss and that she will assess him/her today, after the weight loss was brought to her attention by the surveyor. During a surveyor interview on [DATE] at 10:37 AM with the DNS she revealed that she would expect the nurse to notify the NP, Dietitian, and the family, if a resident has a weight loss. 3b. Record review for Resident ID #304 revealed a progress note dated [DATE], authored by the Registered Dietitian, which states in part, .Estimated fluid needs: ,d+[DATE]ml (26ml/Kg [kilogram]) . Review of the resident's fluid intake from [DATE] through [DATE] revealed the following: -[DATE] 540 mL -[DATE] 360 mL -[DATE] 660 mL -[DATE] 1020 mL -[DATE] 540 mL -[DATE] 940 mL -[DATE] 960 mL -[DATE] 480 mL -[DATE] 840 mL -[DATE] 680 mL -[DATE] 740 mL -[DATE] 840 mL -[DATE] 840 mL Record review failed to reveal evidence that the resident met the minimum amount of fluid intake, per the diet manual, or the estimated fluid needs per the Registered Dietitian's calculations. Additionally the record failed to reveal evidence that the resident refused any fluids. During a surveyor interview on [DATE] at 12:43 PM with the DNS, she acknowledged that the resident was not documented as consuming 1500 mL per the diet manual or the estimated fluid consumption per the Registered Dietitian's calculations. Review of laboratory results obtained on [DATE] revealed the resident Blood Urea Nitrogen (BUN, a medical test that measures the amount of urea nitrogen found in blood. In dehydration, as water decreases and urea is reabsorbed, the BUN rises.) was elevated to 27 from 15 on [DATE] indicating possible dehydration. 4. Record review revealed that Resident ID #303 was admitted to the facility in December of 2023 with diagnoses including, but not limited to, acute kidney injury and heart failure. Review of the resident's demographic information dated [DATE] revealed a diet order for No Added Salt 4G[gram], Phosphorus Restricted diet. Review of a dietary assessment completed in the hospital dated [DATE] revealed a Current Diet Order: No Added Salt 4G, Phosphorus Restricted This patient has no supplements ordered. Record review revealed a physician's order with a start date of [DATE] for a No Salt Packet diet .Regular texture .Thin Consistency, for diet. During a surveyor interview on [DATE] at 8:41 AM with Registered Nurse, Staff D, she acknowledged that the resident was not on a phosphorus restricted diet. During a surveyor interview on [DATE] at 9:55 AM with the Registered Dietitian, she revealed that she was unaware of the resident's diet order from the hospital. During a subsequent surveyor interview on [DATE] at 10:04 AM with Staff D, she revealed that she completed the admission and that she missed the diet order. During a surveyor interview on [DATE] at 10:37 AM with the DNS, she acknowledged that the phosphorus restricted diet was not implemented for this resident. Additionally, she was unable to provide evidence that the facility provided a therapeutic diet when there is a nutritional problem. Refer to F 658 and F 760.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to 1 of 2 residents reviewed for a change in condition, Resident ID #202. Findings are as follows: 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 the facility's diet manual Diet & Dining Manual for Extended Care in a Culture changes Environment from section Fluid Management 2019, states in part, While the fluid intake goals need to be calculated and individualized by the Registered Dietitian, generally the elderly population should take in a minimum of 1500 [milliliters] per day .and preferably up to 2000 [milliliters] per day . According to Elsevier, 2024, .dehydration occurs when an individual excretes too much water without also excreting electrolytes .Diarrhea and vomiting are common causes of dehydration due to rapid fluid loss through the gastrointestinal tract .signs and symptoms .an individual may experience fatigue, dark urine, less frequent urination, dry skin, or dry lips. In addition to these, as severity increases .in severe situations, an individual may experience .death .Blood test results that suggest hypertonic dehydration include elevated blood urea nitrogen (BUN) .elevated sodium (Na) .Individuals with severe dehydration who do not respond to oral rehydration therapy may need to be administered fluids via IV [Intravenously]. According to the Standard Nursing Practice second edition, 2003 .dry mucus membranes are signs of dehydration. Intake and output needs to be monitored to determine body fluid status. Record review revealed Resident ID #202 was admitted to the facility in December of 2023 with diagnoses including, but not limited to, below the knee amputation aftercare, infection in the surgical wound, and a history of congestive heart failure (a weakness of the heart that leads to the buildup of fluid in the lungs and the surrounding tissue). Review of the resident's care plan revealed a goal that the resident will be safely transferred back to the community and that the resident was admitted to the facility for short term placement. The care plan further revealed that the resident was not exhibiting impaired cognition on admission. Record review revealed the resident had a foley catheter in place for urinary retention. Record review of a progress note dated [DATE], authored by Nurse Practitioner (NP), Staff A, revealed the resident stated s/he was feeling well and denied fatigue. Record review of a nursing admission note, dated [DATE], revealed the resident was alert and able to make needs known and had a foley catheter in place. Record review revealed the following physician's orders: Loperamide HCL oral solution 1 MG/7.5 ml (milliliter) give 15 ml by mouth every 6 hours as needed for diarrhea dated [DATE]. Torsemide (a medication used to decrease fluid buildup in the body) Oral Tablet 20 milligrams (mg) to be given once a day, alternating every other day with Torsemide Oral Tablet 40 mg dated [DATE]. Record review revealed on [DATE] labs were obtained which indicated an increased sodium (Na) level of 146 milliequivalents per liter (mEq/L; normal lab value ,d+[DATE] mEq/L) and an elevated BUN (Blood Urea Nitrogen- an indicator of kidney function) of 31 milligrams per deciliter, (MG/DL; normal lab value ,d+[DATE] MG/DL). Further review revealed a physician's order to hold the Torsemide for 2 days (,d+[DATE] and [DATE]). Additional review revealed poor fluid intake was documented as 0 ml and no urine output was documented. Record review of a nursing progress note dated [DATE] indicated the resident was declining and lethargic. Record review revealed on [DATE] labs were obtained which indicated a Na level of 150 mEq/L and BUN of 32 MG/DL. Further review revealed a new physician's order for the Torsemide to be held indefinitely, which was not transcribed into the resident's Medication Administration Record (MAR). Additionally, no urine output was documented. Record review revealed a progress note dated [DATE], authored by Nurse Practitioner (NP) Staff A, which states in part, Diarrhea .Imodium [Loperamide] PRN [as needed] diarrhea . Further review revealed the resident's mouth was dry on assessment and to encourage fluids. Record review revealed on [DATE] the resident had experienced diarrhea three times. Further review revealed the Loperamide was not administered for the diarrhea. Additional review revealed the resident was experiencing confusion and delusions and and no urine output was documented. Record review revealed on [DATE] Torsemide 20 mg was administered in error, poor oral intake was documented, 960 ml, and the resident continued to experience diarrhea. Further review revealed the Loperamide was not administered. Additionally, labs were obtained which indicated abnormal values of Na=148 and BUN=29. Record review revealed on [DATE] labs were obtained which indicated abnormal values of Na=148 and BUN= 32. Further review revealed a chest Xray was ordered and obtained which indicated the resident was suffering from pulmonary edema (fluid in the lungs). A new physician's order for Torsemide 40 mg to be administered once was put in place however Torsemide 40 mg was administered twice in error. Additionally, poor oral intake was documented, 480 ml, and the NP, Staff A, documented that the resident was lethargic and grabbing at the air. Record review revealed on [DATE] administration of the Torsemide was attempted however the resident refused the medication. Further review revealed a nursing progress note that the resident was very fatigued and weak. Additionally, poor oral intake was documented, 600 ml and no urine output was documented. Record review revealed on [DATE] the resident was lethargic and refused meals and fluids. Further review revealed a nursing progress note indicating that the resident's family was concerned with his/her lethargy and had asked if the resident was receiving the wrong medications. The note further indicated that the nurse stated that the resident was not receiving the wrong medications, despite that the resident had been receiving the Torsemide in error, as stated above. Additionally, no urine output was documented. Record review revealed on [DATE] the resident refused medications and meals and poor oral intake was documented, 120 ml. Additionally, no urine output was documented. Record review revealed on [DATE] the resident experienced diarrhea twice and Loperamide was not administered. Poor oral intake was documented, 720 ml and a new physician's order to administer ,d+[DATE] Normal Saline (fluids) via IV for hydration. Additionally, labs were obtained which indicated worsening abnormal values of Na= 152 and BUN= 43. Record review revealed an NP note dated [DATE], authored by Staff A, indicating the resident had multiple episodes of lethargy, had a weight loss of 11.5 pounds since admission (12 days), and hospice care was discussed with the family. Further review revealed that the family was not in agreement with a hospice admission and it was noted that the resident would continue to benefit from skilled therapy. Additionally, the note indicated that the resident was at high risk for rehospitalization due to multiple active comorbidities. Record review failed to reveal evidence that a hospital transfer was offered or executed due to the resident's decline in health status. Record review revealed on [DATE] the resident experienced diarrhea and Loperamide was not administered. Further record review revealed a nursing note dated [DATE] at 10:48 AM that indicated the resident was found not breathing, cool to touch, pupils dilated/non-reactive. Resident expired at 10:38 AM. Record review indicated that the resident was suffering from dehydration prior to his/her death at the facility as evidenced by multiple days of a poor oral fluid intake, fluid loss through diarrhea, a medication that depletes fluid in the body administered multiple times in error, abnormal lab values that are indicative of dehydration, and the need for IV fluids for hydration given on [DATE], the evening prior to his/her death on the morning of [DATE]. During a surveyor interview on [DATE] at 12:06 PM with Registered Nurse, Staff B, she acknowledged that the resident should not have received the Torsemide on the above-mentioned dates. Additionally, she could not provide evidence that the Loperamide was administered to the resident as needed for diarrhea. During a surveyor interview on [DATE] at 9:46 AM with Staff A, she indicated that the resident was lethargic and confused at times during his/her admission as well as experiencing diarrhea. She further indicated that the resident may have been dehydrated due to the loose stools. Additionally, she indicated that the resident's Na and BUN levels were elevated, and she would have expected the Torsemide to be held as ordered. During a surveyor interview on [DATE] at 10:45 AM with the Director of Nursing Services, she indicated that she would expect urine output to be documented for a resident with a foley catheter and for Resident ID #202. She further indicated that she would have expected the Torsemide to be held as ordered and Loperamide to be given for diarrhea as ordered. Refer to F 692 and F 760.

Based on record review and staff interview it has been determined that the facility failed to ensure that the residents are free from significant medication errors for 1 of 2 residents reviewed who expired in the facility, Resident ID #202. Findings are as follows: 1a. Record review revealed Resident ID #202 was admitted to the facility in December of 2023 with diagnoses including, but not limited to, below the knee amputation aftercare, infection in the surgical wound, and a history of congestive heart failure (a weakness of the heart that leads to the buildup of fluid in the lungs and the surrounding tissue). Record review revealed the following physician's orders: Torsemide (a medication used to decrease fluid buildup in the body) Oral Tablet 20 milligrams (mg) to be given once a day, alternating every other day with Torsemide Oral Tablet 40 mg. Record review revealed labs were obtained on [DATE] which indicated an increased sodium (Na) level of 146 milliequivalents per liter (mEq/L; normal lab value ,d+[DATE] mEq/L) and an elevated BUN (Blood Urea Nitrogen- an indicator of kidney function) of 31 milligrams per deciliter, (MG/DL; normal lab value ,d+[DATE] MG/DL). Record review revealed a physician's order dated [DATE] to hold the Torsemide for 2 days (,d+[DATE] and [DATE]). Record review revealed labs obtained on [DATE] indicated an increase in both the resident's Na level to 150 mEq/L and BUN to 32 MG/DL . Record review revealed a new physician's order was obtained on [DATE] to continue to hold the Torsemide indefinitely. Further record review revealed this order was not transcribed into the resident's Medication Administration Record (MAR). Review of the [DATE] and [DATE] MARs revealed that the resident was administered the Torsemide in error on the following dates: -[DATE]- Torsemide 20 mg -[DATE]- Torsemide 40 mg -[DATE]- Torsemide 20 mg -[DATE]- The resident was offered the medication but refused -[DATE]- The resident was offered the medication but refused -[DATE]- Torsemide 40 mg This indicates that the Torsemide was not held from [DATE] through [DATE] as ordered. Further record review revealed the following abnormal labs: -[DATE] - Na=148, BUN=29 -[DATE]- Na=148, BUN= 32 -[DATE]- Na= 152, BUN= 43 1b. Record review revealed documentation that the resident experienced diarrhea on the following days: -[DATE]- twice -[DATE]- three times -[DATE]- once -[DATE]- twice -[DATE]- once Record review revealed a physician's order dated [DATE] for Loperamide HCL oral solution 1 MG/7.5 ml (milliliter) give 15 ml by mouth every 6 hours as needed for diarrhea. Record review revealed a progress note dated [DATE], authored by Nurse Practitioner (NP) Staff A, which states in part, Diarrhea .Imodium [Loperamide] PRN [as needed] diarrhea . Further review revealed the resident's mouth was dry on assessment and to encourage fluids. Record review of the [DATE] and [DATE] MARs failed to reveal evidence that the Loperamide HCL was administered to the resident on ,d+[DATE],,d+[DATE],[DATE],,d+[DATE] or [DATE] when s/he had diarrhea. Record review revealed the resident expired at the facility on [DATE] at 10:38 AM. Record review indicated that the resident was suffering from dehydration prior to his/her death at the facility as evidence by multiple days of fluid loss through diarrhea, a medication that depletes fluid in the body administered multiple times in error and abnormal lab values that are indicative of dehydration. During a surveyor interview on [DATE] at 12:06 PM with Registered Nurse, Staff B, she acknowledged that the resident should not have received the Torsemide on the above-mentioned dates. Additionally, she could not provide evidence that the Loperamide was administered to the resident as needed for diarrhea. During a surveyor interview on [DATE] at 9:46 AM with Nurse Practitioner, Staff A, she indicated that the resident was lethargic and confused at times during his/her admission as well as experiencing diarrhea. She further indicated she would have expected the Torsemide to be held as ordered. Additionally, she could not provide evidence that the Loperamide was administered as needed for diarrhea. During a surveyor interview on [DATE] at 10:45 AM with the Director of Nursing Services, she indicated that she would have expected the Torsemide to be held as ordered and Loperamide to be given for diarrhea as needed. Additionally, she was unable to provide evidence that the facililty ensured that the resident was free from significant medication errors. Refer to F 658 and F 692 46118