Every finding on record at Coventry Operations RI LLC DBA Respiratory and Reh

Based on record review and staff interview, the facility failed to conduct and document a comprehensive facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations (including nights and weekends) and emergencies. The facility must review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment and maintain a plan to maximize recruitment and retention of direct care staff.Findings are as follows:Review of a community reported complaint received by the Rhode Island Department of Health on 6/23/2026 alleges in part, that the facility has a severe and persistent staffing shortage.Review of a document titled, 2025 Facility Assessment revealed the document had been signed by the former administrator and former Director of Nursing Services (DNS) on 3/30/2026. The document states in part, .Function- Sufficiency Analysis Summary.4. Please document total #[number]/average/range of staff required to ensure sufficient number of qualified staff are available to meet each resident's needs: Kindly reference the attached Staffing and Personnel Worksheet in the Attachments section of this Facility Assessment.Further review of the 2025 Facility Assessment revealed multiple sections for Supporting Documents that state, No records were found. Additional review failed to reveal evidence that a Staffing and Personnel Worksheet had been completed in the facility assessment.Additional review of the 2025 Facility Assessment revealed previous employees listed as the Administrator and the DNS, and not the current Administrator and DNS.Furthermore, the facility failed to provide evidence of a plan to maximize recruitment and retention of direct care staff.During a surveyor interview on 6/24/2026 at 1:28 PM with the DNS, she acknowledged that the Facility Assessment does not accurately reflect the staffing patterns of the facility. Additionally, she could not provide evidence of a recruitment and retention plan for direct care staff.

Based on clinical record review and staff interview, the facility failed to ensure that a resident remained free from physical abuse for 1 of 3 residents reviewed, pertaining to Resident ID #2 when Resident ID #1 physically assaulted the resident by pushing him/her against a door and holding a butter knife to his/her neck.Findings are as follows:Review of a facility reported incident submitted to the Rhode Island Department of Health on 6/1/2026 revealed that Resident ID #1 pushed Resident ID #2 against a door and placed a butter knife against his/her neck. Both residents were immediately separated by staff. There were no injuries to either resident. Resident ID #1 refused to hand the butter knife to staff but did hand it to the police officer shortly thereafter. Resident ID #1 was sent to the hospital for further evaluation.Record review revealed the alleged perpetrator, Resident ID #1, was admitted to the facility in September of 2025 with diagnoses including, but not limited to, dementia with behavioral disturbances, major depressive disorder, anxiety disorder, adjustment disorder, and alcohol dependence.Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a score of 99 which indicates the interview was unable to be completed.Review of a care plan focus area dated 9/30/2025, revealed Resident ID #1 has impaired cognition and exhibits verbal and physical behaviors, ineffective coping skills, and poor anger management.Record review revealed that the victim, Resident ID #2, was admitted to the facility in February of 2015 with diagnoses including, but not limited to, dementia with behavioral disturbances, paranoid schizophrenia, personality disorder, major depressive disorder, and anxiety disorder. Record review of a Quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status score of 8 out of 15, indicating moderately impaired cognition.Review of a care plan focus area dated 3/4/2015, revealed the resident has a history of verbal outbursts directed toward others. Interventions include, but are not limited to, monitor for signs of agitation, redirect, and have the resident refocus on something positive. Record review of a progress note for Resident ID #1, dated 6/1/2026 at 3:48 PM, revealed that she/he was sent to the hospital for evaluation after an assault, pushing a resident, and threatening a resident with a butter knife.Record review of a progress note for Resident ID #2, dated 6/1/2026 at 2:00 PM, found that this nurse witnessed this resident be pushed by another resident in the hall. This nurse quickly intervened and multiple staff intervened. This nurse removed this resident from the other resident and brought him/her back to his/her room. Resident had no complaints of pain and no new skin issues noted. During a surveyor interview conducted on 6/17/2026 at approximately 1:15 PM, the Director of Nursing Services (DNS) stated that when Resident ID #2 walked past Resident ID #1, Resident ID #1 unexpectedly stood up, pursued Resident ID #2, cornered him/her against a door, and held a butter knife near his/her neck. The DNS further stated that Resident ID #1 refused staff requests to relinquish the butter knife, and law enforcement was contacted to assist with the situation. She was unable to provide evidence that Resident ID #2 was kept free from physical abuse.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to provide necessary respiratory care and services in accordance with professional standards of practice for a resident who requires mechanical ventilation (a life-support therapy that assists or replaces natural breathing by delivering oxygen and removing carbon dioxide through a ventilator) who experienced chest pain and was sent via rescue to an acute care hospital for evaluation, Resident ID #1, who ultimately expired in transit to the hospital. Further, the facility failed to ensure that respiratory staff provide respiratory care consistent with professional standards of practice for 4 of 6 respiratory staff reviewed, Staff A, C, D, and E to ensure that a physician's order for mechanical ventilation settings were in place for 1 of 1 resident reviewed for non-invasive ventilation (NIV, a machine that provides breathing support using an external mask or other component, eliminating the need for an invasive surgical airway or breathing tube), Resident ID #1. Additionally, the facility failed to ensure that a resident who requires mechanical ventilation receives the mechanical ventilation settings as prescribed by the provider for 2 of 5 residents reviewed, Resident ID #s 1 and 3.Findings are as follows:Review of a complaint received by the Rhode Island Department of Health on [DATE] alleges in part, .[Resident ID #1].had chest pains so [s/he] agreed to go to the hospital in the ambulance.We [family member] first got a call from a doctor.from [the acute care hospital] telling us that [Resident ID #1] had not made it to the hospital and died on [his/her] way .Additionally, the complaint alleges that the facility failed to ensure that Resident ID #1 was provided with the necessary respiratory equipment prior to leaving the facility via rescue and that Resident ID #1 had been receiving the incorrect ventilator settings.1a. Review of an undated facility policy titled, Ventilator Patient External Transport Procedure states in part, .ensure safe transport of mechanically ventilated patients outside the facility for.hospital transfer while maintaining adequate ventilation and patient stability.All ventilated patients requiring external transport must be assessed by Respiratory Therapy prior to departure to ensure appropriate equipment. Indications.Hospital transfer.Emergency transport. Required Equipment * Portable ventilator with charged battery.Transport Procedure.Transfer patient to portable ventilator if required.According to an article published in April of 2021 in the American Journal of the Medical Sciences titled, Non-Rebreather Mask [NRM, a type of oxygen mask that delivers high concentrations of oxygen to individuals who can breathe on their own]: A Bridge Worth Crossing? states in part, .NRM does not provide any positive pressure to help support the patient mechanically.Record review revealed Resident ID #1 was admitted to the facility in March of 2026 with diagnoses including, but not limited to, duchenne or [NAME] muscular dystrophy (a severe, progressive genetic disorder characterized by the wasting away of skeletal, heart, and respiratory muscles), dependence on respirator (ventilator) status, and chronic respiratory failure.Review of the care plan revealed a focus area dated [DATE] indicating that Resident ID #1 has an alteration in respiratory status and is ventilator dependent. Further, the care plan revealed that s/he receives ventilation support using non-invasive ventilation via mouthpiece ventilation equipment during the daytime. Additionally, s/he uses nasal pillows [soft inserts that fit directly into the nostrils to provide pressurized air from the ventilator machine via a flexible tube to help keep the airway open, improve breathing, and prevent an individual from not breathing] at nighttime. Further, interventions include, but are not limited to, ventilator check assessments to be conducted every six hours and to use the ventilator for respiratory support per the physician's order.Review of a progress note dated [DATE] at 12:59 AM revealed that Resident ID #1 had complained of chest pain and requested to be transferred to the hospital, and s/he was transported via 911.Review of the Emergency Medical Services (EMS) Run Report documentation dated [DATE] revealed that EMS was dispatched to the facility for Resident ID #1 who was complaining of chest pain. The report further revealed that Resident ID #1 was on a bilevel positive airway pressure (BiPAP, a noninvasive ventilator that helps people breathe easier by delivering pressurized air through a face or nasal mask, alternating between a higher pressure for inhaling and a lower pressure for exhaling) device at night. Furthermore, Resident ID #1 was placed on a non-rebreather mask for transportation to the hospital per instruction from the Respiratory Therapist (RT), Staff A. Additionally, Resident ID #1 complained to EMS that s/he was unable to breathe, thus rescue personnel removed the non-rebreather mask and began assisting Resident ID #1 with ventilations using a bag valve mask (a handheld, manual device that provides positive pressure ventilation to individuals who are not breathing or not breathing adequately, often used in emergency situations). Lastly, the report indicates that while in transit to the hospital, Resident ID #1 became unresponsive, s/he stopped breathing, and his/her heart had stopped.Review of the hospital documentation dated [DATE] revealed that Resident ID #1 arrived at the hospital without a pulse or respirations; and was pronounced dead.Record review revealed the following ventilator check assessments completed by Staff A, on the following dates and times:-[DATE] at 9:09 PM: Resident ID #1 was received by Staff A on his/her daytime mouthpiece type ventilator and showed no signs of respiratory distress. Staff A switched Resident ID #1 to his/her nighttime nasal pillows vent [VOCSN, a multi-function respiratory device that combines five separate respiratory therapies into a single portable system] at 8:22 PM. It further revealed that Resident ID #1 tolerated his/her respiratory treatment well, his/her ventilator alarms were on and functioning, and that a bag valve mask was available at his/her bedside.-[DATE] at 12:17 AM: At 10:38 PM (on [DATE]), Resident ID #1 complained of chest pain and Staff A entered to provide him/her respiratory assistance. Resident ID #1 continued to complain of chest pain and a bloated belly and was transported to the hospital at 11:45 PM on a non-rebreather mask.During a surveyor interview on [DATE] at approximately 12:45 PM with the Vent Program Manager, in the presence of RT, Staff B, they indicated that Resident ID #1 is ventilator dependent and is unable to breathe on his/her own. They further revealed that the VOCSN ventilator is portable and can be transported with a resident in the event of an emergency. Additionally, they revealed that Resident ID #1 ideally should have been transported with the VOCSN ventilator, or a bag valve mask used in place of the ventilator, instead of using a non-breather mask to transport Resident ID #1 to the hospital.During a surveyor interview on [DATE] at 9:09 AM with Staff A, she revealed that she was the RT scheduled to care for Resident ID #1 on the evening of [DATE] and began her shift at approximately 7:00 PM. She revealed that Resident ID #1 presented at his/her baseline when she completed her first ventilator check assessment at approximately 8:00 PM; and had switched Resident ID #1 from his/her daytime ventilator to the VOCSN ventilator with nasal pillows per his/her nighttime routine. She revealed that Resident ID #1 had complained of chest pain shortly after his/her first ventilator check assessment and she informed the nurse. She further revealed that after Resident ID #1 initially refused to be hospitalized , but, as the chest pain continued, Resident ID #1 agreed to go to the hospital. Staff A revealed that she stayed with Resident ID #1 to monitor his/her respiratory status and provide necessary respiratory care while waiting for rescue personnel to arrive. Staff A further revealed that, when rescue personnel arrived on scene, they informed her that they did not have a ventilator for the resident to use. Staff A indicated that she had removed Resident ID #1 from his/her ventilator and placed him/her on a non-rebreather mask for transport to the hospital and indicated to rescue personnel that Resident ID #1 would crash fast on a non-rebreather mask and offered rescue personnel a bag valve mask to take. When Staff A was questioned by the surveyor about her choice to place a non-rebreather mask on Resident ID #1 for his/her transport to the hospital, she revealed that Resident ID #1 was stable at the time of the rescue personnel's arrival, s/he had stable blood oxygen levels, and was still alert and speaking. Staff A insisted that she offered rescue personnel a bag valve mask in addition to the non-rebreather mask that she had placed on the resident, but rescue personnel declined because they had a bag valve mask. When the surveyor further inquired as to why Resident ID #1 was not transported with his/her ventilator, Staff A revealed that she did not think about it despite rescue personnel informing Staff A that they did not have a ventilator for the resident. Additionally, she revealed that Resident ID #1 was transported from the facility on a non-rebreather mask.During a surveyor interview on [DATE] at 9:47 AM with the Director of Nursing Services (DNS), she revealed that a bag valve mask should have been used if Resident ID #1 was removed from his/her ventilator to be transported to the hospital. Additionally, she revealed that it is not the facility's practice to send a resident with his/her ventilator when 911 is called. However, the policy states .Hospital transfer.Emergency transport. Required Equipment * Portable ventilator with charged battery .During a surveyor interview on [DATE] at 9:50 AM with the Administrator, he revealed that he would expect staff to follow the facility's policy regarding transportation of a mechanically vented resident. Further, he was unable to provide evidence that the facility followed their policy relative to transporting a ventilator dependent resident with the required equipment that includes a portable ventilator. Additionally, he indicated that he would expect staff to provide the ventilator only if the rescue personnel had requested it.During a surveyor interview on [DATE] at approximately 10:35 AM with the Pulmonary Consultant, Nurse Practitioner, she revealed that she would not expect staff to place a non-rebreather mask on a ventilator dependent resident. She further revealed that she would expect the facility to follow their policy regarding transporting mechanically vented residents. Additionally, she revealed that in the absence of a ventilator, she would expect staff to use a bag valve mask.During a surveyor interview on [DATE] at approximately 10:50 AM with RT, Staff C, she revealed that the facility has transported a ventilator dependent resident with his/her ventilator during an emergency in the past. Additionally, she revealed that all the VOCSN ventilators they use for their residents are portable. This indicates that the VOCSN ventilator for Resident ID #1 could have accompanied the resident to the hospital. During a follow up surveyor interview on [DATE] at approximately 1:45 PM with the Vent Program Manager, she declined to answer whether she would place Resident ID #1 on a non-rebreather mask but indicated that placing him/her on a non-rebreather mask, the resident would eventually crash.1b. Review of an undated facility policy titled, Non-Invasive Ventilator (NIV) Policy & Procedure states in part, .Purpose.Promote patient safety and improve respiratory support management.Procedure.Verify physician/provider order and prescribed settings.Record review revealed Resident ID #1 utilized the following three ventilators while at the facility between [DATE] through [DATE]:-Astral (daytime mouthpiece ventilator)-LTV (nighttime nasal pillow ventilator)-VOCSN (nighttime nasal pillow ventilator)Record review revealed the following physician's orders for the resident's ventilators with the prescribed settings:-[DATE] Astral ventilator:-Tidal volume (VT, the amount of air inhaled or exhaled during a normal breath) 600-Respiratory rate (RR, the number of breaths a person takes per minute) 8-Positive end-expiratory pressure (PEEP, the pressure in the lungs above atmospheric pressure at the end of exhalation that prevents the lungs from collapsing when breathing out) 0-Fraction of inspired oxygen (FiO2, refers to the oxygen concentration; room air is considered 21% oxygen) 21%-[DATE] LTV ventilator:-VT 1100-RR 14-PEEP 6-FiO2 21%-Pressure support (PS, a mode of mechanical ventilation that assists patients by providing a preset level of pressure during inhalation) 8Record review failed to reveal evidence of a physician's order for the VOCSN ventilator or ventilator settings.Additional record review revealed that the facility discontinued using the LTV ventilator and began using the VOCSN ventilator beginning at nighttime on [DATE].Further record review revealed that Resident ID #1 utilized the VOCSN ventilator at nighttime without a physician's order or associated ventilator settings in place from [DATE] through [DATE], when s/he was emergently transported via rescue to the hospital where s/he was pronounced dead on arrival.During a surveyor interview on [DATE] at approximately 11:25 AM with the Physician Assistant (PA), he revealed that he expects a provider's order to be in place for a ventilator and ventilator settings. Additionally, he would expect that staff would verify the ventilator order and settings each time a ventilator check assessment is conducted.Record review of the ventilator check assessments conducted between [DATE] through [DATE] revealed 23 ventilator check assessments were completed for Resident ID #1 while s/he utilized the VOCSN ventilator, indicating 23 of 23 opportunities were missed for staff to identify that there was no provider's order or settings for the VOCSN ventilator involving Staff A, C, D, and E.Record review revealed the following clinical competency validations for ventilator management for the above-mentioned RTs:-[DATE] Staff A: Revealed criteria as Met for demonstrating knowledge of what is included in complete and appropriate physician orders and the ability to adjust the ventilator controls to the ordered settings.-[DATE] Staff C: Revealed criteria as Met for verifying completeness of a physician's ventilator order and the ability to adjust the ventilator settings to the prescribed parameters.-[DATE] Staff D: Revealed criteria as Met for demonstrating knowledge of what is included in complete and appropriate physician orders and the ability to adjust the ventilator controls to the ordered settings.-[DATE] Staff E: Revealed criteria as Met for verifying completeness of a physician's ventilator order and the ability to adjust the ventilator settings to the prescribed parameters.Record review of a ventilator check assessment dated [DATE] at 1:58 AM completed by Staff C, revealed that Resident ID #1 was on the VOCSN ventilator as ordered and indicated that the ventilator settings were in the electronic medical record, despite having no order or settings for the ventilator.During a surveyor interview on [DATE] at approximately 5:00 PM with Staff C, she acknowledged that there was no physician's order in place for the VOCSN ventilator or any prescribed settings for the ventilator and indicated that there should be an order. She revealed that when ventilator check assessments are conducted, the RT is expected to verify the physician's order for the ventilator and the prescribed settings. She further revealed that if there is no order in place, the RT is expected to contact a provider. She was unable to explain why Resident ID #1 was receiving ventilation support from a ventilator that was not ordered by a provider nor had prescribed ventilation settings to program it.During a surveyor interview on [DATE] at 12:53 PM with the DNS, she was unable to provide evidence that the facility provided necessary respiratory care and services in accordance with professional standards of practice and per the facility policy.The facility failed to ensure that Resident ID #1, a ventilator-dependent resident with chronic respiratory failure, was provided with the necessary respiratory equipment and physician-ordered ventilator settings in accordance with professional standards of practice and facility policy. Specifically, the facility failed to ensure that Resident ID #1 was transported with appropriate ventilatory support during an emergency transfer to the hospital and failed to ensure that a physician's order and prescribed settings were in place for the resident's VOCSN ventilator from [DATE] through [DATE]. As a result, Resident ID #1, who staff acknowledged was unable to breathe independently and would crash fast without appropriate ventilatory support, was transported on a non-rebreather mask rather than a portable ventilator or bag valve mask, became unresponsive during transport, and was pronounced dead upon arrival at the hospital. These deficient practices placed the resident at immediate risk for serious harm, impairment, or death. 2a. Review of a physician's ventilator order for Resident ID #1 dated [DATE] revealed in part, the following ventilator settings for the LTV vent:-VT: 1100-PEEP: 6-PS: 8Record review revealed that Resident ID #1 did not receive his/her LTV ventilator settings as prescribed as evidence by the following ventilator check assessments:-[DATE] at 9:22 PM: PS 15, PEEP 8-[DATE] at 1:54 AM: PS 15, PEEP 8-[DATE] at 8:29 PM: PS 2, VT 850During a surveyor interview on [DATE] at approximately 12:40 PM with the Vent Program Manager, she acknowledged that Resident ID #1 did not receive his/her ventilator settings as prescribed.During a surveyor interview on [DATE] at approximately 11:25 AM with the PA, he revealed that he expects staff to follow the prescribed ventilator settings. He further indicated that staff do not have the autonomy to adjust ventilator settings without first speaking to a provider.2b. Record review revealed Resident ID #3 was readmitted to the facility in April of 2026 with a diagnosis including, but not limited to, dependence on respirator (ventilator) status.Review of a care plan focus area dated [DATE] revealed that Resident ID #3 is ventilator dependent with an intervention to use the ventilator for respiratory support per the physician's order.Review of a physician's order dated [DATE] revealed in part, the following ventilator setting:-FiO2: 3 liters of oxygenDuring a surveyor observation and simultaneous interview on [DATE] at approximately 1:40 PM of Resident ID #3, in the presence of Staff C, Resident ID #3 was noted lying in his/her bed connected to his/her ventilator. Further, his/her ventilator settings were observed, and s/he was noted to be receiving only room air, and was not receiving the 3 liters of oxygen, as prescribed.During a surveyor interview immediately following the above observation with Staff C, she was unable to provide evidence that Resident ID #3 had his/her ventilator settings set to include the 3 liters of oxygen, as prescribed.During a surveyor interview on [DATE] at 12:53 PM with the DNS, she was unable to provide evidence that the facility provided necessary respiratory care and services in accordance with professional standards of practice and per the facility's policies.Cross reference F 842

Based on clinical record review and staff interview, the facility failed to maintain complete and accurate resident medical records in accordance with accepted professional standards and practices for 1 of 1 resident reviewed for non-invasive ventilation (NIV, a machine that provides breathing support using an external mask or other component, eliminating the need for an invasive surgical airway or breathing tube), Resident ID #1. Findings are as follows:Review of a complaint received by the Rhode Island Department of Health on 5/19/2026 alleges, in part, that Resident ID #1 had been receiving the incorrect ventilator settings.Record review revealed Resident ID #1 was admitted to the facility in March of 2026 with diagnoses including, but not limited to, duchenne or [NAME] muscular dystrophy (a severe, progressive genetic disorder characterized by the wasting away of skeletal, heart, and respiratory muscles), dependence on respirator (ventilator) status, and chronic respiratory failure.Review of the care plan revealed a focus area dated 3/5/2026 indicating that Resident ID #1 has an alteration in respiratory status and is ventilator dependent. Further, the care plan revealed that s/he receives ventilation support using non-invasive ventilation via mouthpiece ventilation equipment during the daytime. Additionally, s/he uses nasal pillows [soft inserts that fit directly into the nostrils to provide pressurized air from the ventilator machine via a flexible tube to help keep the airway open, improve breathing, and prevent an individual from not breathing] at nighttime. Further, interventions include, but are not limited to, ventilator check assessments to be conducted every six hours and to use the ventilator for respiratory support per the physician's order.Review of an undated facility policy titled, Non-Invasive Ventilator (NIV) Policy & Procedure states in part, .Purpose.Promote patient safety and improve respiratory support management.Procedure.Verify physician/provider order and prescribed settings.Record review revealed Resident ID #1 utilized the following three ventilators while at the facility between 3/2/2026 through 3/14/2026:-Astral (daytime ventilator)-LTV (nighttime ventilator)-VOCSN (nighttime ventilator)Record review revealed the following physician's order for the resident's LTV ventilator with the prescribed settings:-Tidal volume (VT, the amount of air inhaled or exhaled during a normal breath) 1100-Respiratory rate (RR, the number of breaths a person takes per minute) 14-Positive end-expiratory pressure (PEEP, the pressure in the lungs above atmospheric pressure at the end of exhalation that prevents the lungs from collapsing when breathing out) 6-Fraction of inspired oxygen (FiO2, refers to the oxygen concentration; room air is considered 21% oxygen) 21%-Pressure support (PS, a mode of mechanical ventilation that assists patients by providing a preset level of pressure during inhalation) 8Record review revealed that the facility discontinued using the LTV ventilator and began using the VOCSN ventilator at nighttime beginning on 3/4/2026 through 3/14/2026.Review of the March 2026 Treatment Administration Record revealed that staff continued to document that Resident ID #1 was receiving his/her LTV ventilator at the prescribed settings as denoted above, on the following dates, after it was discontinued on 3/4/2026:-3/4-3/5-3/6-3/8-3/9-3/10-3/11-3/12-3/14/2026During a surveyor interview on 5/22/2026 at approximately 11:25 AM with the Physician Assistant, he revealed that he expects staff to document accurately.During a surveyor interview on 5/22/2026 at 12:53 PM with the Director of Nursing Services, she was unable to provide evidence that the facility maintained accurate medical records for Resident ID #1.Cross reference F 695

Based on clinical record review and staff interview, the facility failed to provide and document sufficient preparation and orientation to the resident to ensure a safe and orderly discharge from the facility by communicating the appropriate information for 1 of 1 resident reviewed for a discharge to his/her home, Resident ID #4.Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 4/14/2026 revealed that the resident was discharged with a plan of care that was incomplete.Record review revealed the resident was admitted to the facility in March of 2026, with diagnoses including but not limited to, dementia, chronic obstructive pulmonary disorder, gastro-esophageal reflux disorder, history of venous thrombosis and anxiety disorder. The resident was discharged with home care services on 4/6/2026.Record review of a progress note authored by Physician's Assistant (PA), Staff A, on the day of the resident's discharge revealed that the resident should follow up with his/her primary physician, a neurologist, a gastroenterologist, a pulmonologist, a vascular physician and a psychologist.Record review of a form titled Continuity of Care Discharge/Transfer of Patient Form which was provided to and signed by the resident representative on the day of discharge revealed the following sections were left blank:-Discharging facility contact person/ phone number-Physician who will follow this patient after discharge including the name, phone number-and if physician was notified-The phone number to the referral home care agency-The section titled call physician if-Follow up appointments with phone numbersAdditionally, there failed to be documentation that the resident should see his/her primary physician, a neurologist, a gastroenterologist, a pulmonologist, a vascular physician, and a psychologist after discharge as documented in Staff A's, progress note.During a surveyor interview with Staff A on 4/27/2026 at approximately 9:15 AM, he acknowledged that the Continuity of Care Discharge/ Transfer of patient form was missing the documentation listed above. He further revealed that he would expect the form to document the list of physicians that the resident needed to follow up with after discharge.During a surveyor interview on 4/27/2026 at 10:36 AM with Licensed Practical Nurse, Staff B, she acknowledged that she had assisted with the resident's discharge. She acknowledged that the discharge form was not complete and was missing the above-mentioned components.During a surveyor telephone interview with Social Worker, Staff C, on 4/27/2026 at 8:39 AM, she acknowledged she was involved with the resident's discharge and indicated that she set up his/her homecare services. She further indicated that she would expect the Continuity of Care Discharge/Transfer of patient form to be filled out completely and could not explain why it was not. During a surveyor interview on 4/27/2026 at 11:53 AM with the Director of Nursing Services, she could not provide evidence that the facility provided and documented sufficient preparation and orientation to the resident to ensure a safe and orderly discharge.

Based on clinical record review and staff interview, the facility failed to provide a resident who is unable to carry out activities of daily living, the necessary services to maintain good grooming and personal hygiene for 1 of 3 residents who were reviewed for showers, Resident ID #4.Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 4/14/2026 alleged that the resident was found with noticeably greasy hair, and the nurse was unable to determine when the resident had last received a shower. It further alleged that it wasn't until after the resident's family voiced a complaint that the resident received a shower.Record review revealed the resident was admitted to the facility in March of 2026, with diagnoses including but not limited to dementia, muscle weakness, difficulty walking and unsteadiness on his/her feet.Record review of the Discharge Minimum Data Set assessment dated [DATE] revealed s/he requires partial/moderate assistance with showering or bathing.Record review of the facility task documentation for Tub/ Shower revealed the resident is scheduled to receive a shower every Friday on the 3:00 PM to 11:00 PM shift. Review of the documentation from 3/26/2026, until 4/6/2026, revealed no documented showers. Indicating that the resident would have missed his/her scheduled shower on 3/27/2026, and on 4/3/2026.Record review of the facility task documentation for Bathing from 3/26/2026, until 4/6/2026 revealed one documented shower dated 4/6/2026 at 12:30 PM. This was the day the resident was discharged home. Record review of the clinical record failed to reveal evidence that the resident had been offered a shower, or refused a shower on 3/27/2026, or on 4/3/2026.During a surveyor interview on 4/27/2026 at 11:53 AM with the Director of Nursing Services, she was unable to provide evidence that the resident had received a shower prior to 4/6/2026. Additionally, she indicated that if a shower was offered but refused by the resident, she would expect documentation in the resident's record.

Based on surveyor observation, clinical record review, and staff interviews, the facility failed to ensure a system was in place to prepare and serve fluids in a form designed to meet residents prescribed dietary needs. Specifically, the facility failed to ensure nectar thick liquids (mildly thick fluid consistency required to promote safe swallowing) were prepared according to physician's orders for 1 of 1 resident reviewed who was prescribed nectar thick liquids, Resident ID #21. Additionally, the current styrofoam cup supply, located on 4 of 4 units, was found to consist of 16 fluid (fl.) ounce (oz.) cups instead of the 12 fl. oz cups that were posted in the facility for staff to use for guidance and instructions when preparing thickened liquids. This failure reflects a breakdown in the facility's system for implementing and monitoring prescribed diet modifications and placed residents at risk for choking, aspiration, and other serious complications related to swallowing impairments. Findings are as follows:Record review revealed that Resident ID #21 was admitted to the facility in May of 2025 with diagnoses including, but not limited to, chronic obstructive pulmonary disease and dysphagia (difficulty swallowing).A. Record review revealed a physician's order dated 10/9/2025, for a mechanical soft diet texture and nectar thick liquids.Record review of a Speech Therapy document titled, Evaluation and Plan of Treatment dated 3/11/2026 revealed a fiberoptic endoscopic evaluation of swallowing (FEES, a diagnostic procedure used to assess swallowing function, particularly in individuals with dysphagia) in October of 2025 which revealed aspiration of thin liquids. Further review revealed that Resident ID #21 continues to work with a Speech Therapist four times a week.During a surveyor observation on 4/6/2026 at approximately 12:05 PM, the resident was observed with a large white styrofoam cup containing a red liquid that appeared to be of a thin consistency.During a surveyor interview at the time of the above observation with Resident ID #21, s/he revealed that s/he had already consumed some of the red liquid and stated, I knew it was too thin.During a survey observation and interview immediately following the above observation with the Unit Manager, Licensed Practical Nurse, Staff A, she acknowledged that the consistency of the liquid provided to Resident ID #21 was thin and not of a thickened consistency.During a surveyor interview on 4/6/2026 at 12:12 PM with Nursing Assistant (NA), Staff B, she revealed that she was unaware that the resident required nectar thick liquids. She presented her assignment sheet to the surveyor which indicated the resident required nectar. When asked by the surveyor how she would prepare nectar thick liquids, she was unable to answer. When asked how many fl. oz. were in the cup provided to the resident, she indicated that she gave the resident a 12 oz cup which was not thickened.B. Review of a facility document located in the kitchenettes, on 4 of 4 units, revealed a laminated staff guide with instructions for preparing thickened liquids. This document depicted photos of 5 different size cups indicating the fl. oz. for each cup and how to prepare thickened beverages. The Large Styrofoam cup picture states, 12 oz .3 Nectar Packets .Review of a packet of the thickening agent provided by the facility titled, THICK & EASY states in part, Directions: Add 1 packet.to 4fl. oz of liquid. Stir with a spoon or fork for approximately 15 seconds or until thickener is dissolved. Allow 1-4 minutes for product to reach desired thickness.During a surveyor interview on 4/6/2026 at 12:10 PM with the Speech Therapist, she revealed that the large styrofoam cup given to the resident was 12 fl. oz. and requires 3 packets of the thickening agent to achieve a nectar thickened consistency. Additionally at this time she prepared the resident an alternative drink and stated, I added three packets into this 12 fl. oz. cup.During a surveyor interview on 4/6/2026 at 12:18 PM with NA, Staff C, he revealed that the large Styrofoam cups were 12 fl. oz and required 3 packets of the thickening agent to achieve a nectar thickened consistency.Further review of the large styrofoam cups provided to the residents on 4 of 4 units, revealed that they were 16 fl. oz and not 12 fl. oz, which would require 4 packets to achieve the prescribed nectar consistency.During a survey interview on 4/6/2026 at 1:25 PM with the Central Supply Coordinator, Staff D, he revealed that the large styrofoam cups on the units are 16 fl. oz. He further provided the box that the Styrofoam cups come in, which indicated they are 16 fl. oz.During a surveyor interview on 4/6/2026 at 2:17 PM with the Director of Nursing Services, she revealed that she would expect staff to prepare drinks according to the prescribed orders for the liquid consistency and according to the manufacturer's instructions. She further acknowledged that the cups on the units were 16 fl. oz cups not the 12 fl. oz cups on the sheets provided to staff.The facility's failure to implement and maintain a safe system for the preparation of prescribed thickened liquids, including the use of the correct fluid ounce measurements per manufacturer's instructions, resulted in staff preparing thickened liquids inaccurately, leading to incorrect consistencies. This systemic failure placed residents with dysphagia at risk for aspiration, choking, aspiration pneumonia, and other serious complications that could result in serious injury, harm, impairment, or death.

Based on clinical record review and staff interviews, the facility failed to ensure that irregularities identified by the Consultant Pharmacist during the monthly Medication Regimen Review (MRR) were acted upon for 4 of 4 residents reviewed with outstanding pharmacy recommendations from prior months, Resident ID #s 6, 29, 84, and 107. Findings are as follows:According to the facility policy dated 1/2024 and titled, Medication Monitoring Medication Regimen Review and Reporting, which states in part, .8. The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations should be acted upon within 30 calendar days.1. Record review revealed Resident ID #6 was admitted to the facility in February of 2024 with diagnoses including, but not limited to, chronic diastolic heart failure (a condition when the left ventricle, thickens, stiffens and does not fully relax between beats), schizophrenia (a chronic severe brain disorder causing psychosis), neuropathy (damage to the nerves causing weakness, numbness, and pain usually in the hands and feet) and coronary artery disease (a condition where the major blood vessels supplying the heart become damaged due to a build-up of plaque).Record review revealed a document titled, Consultant Pharmacist's [MRR] Recommendations Pending a Final Response, with review dates between 3/22/2026 and 3/26/2026 indicating that the resident's previous pharmacy review, dated 2/17/2026, made the following recommendations for his/her high-risk medication monitoring:- Diuretic: Furosemide, monitor for signs and symptoms of dehydration, electrolytes, acute kidney injury, monitor for edema, congestion, weight changes- Anticonvulsant: Gabapentin, monitor for signs of seizures, pain assessment, changes in behaviors, therapeutic drug levels, rash, fever and dizziness- Antipsychotic: Paliperidone and Rexulti, monitor side effects including dry mouth, constipation, blurred vision, change in urination, jerking movements in the face, tongue and jaw, swelling in hands, ankles or feet, drooling, disturbed gait and restlessness.- Antiplatelet: Aspirin, monitor for signs/symptoms of bleeding/bruising and monitor for signs/symptoms of thromboembolism Record review failed to reveal evidence that the above monitoring recommendations were implemented.Additionally, it was not until 4/9/2026, after the surveyor had asked the facility to review the resident's MRR document, that the provider signed in agreement with the above-mentioned recommendations, from February and March 2026. During a surveyor interview on 4/10/2026 at approximately 2:30 PM with the Director of Nursing Services, she was unable to provide evidence that Resident ID #6's MRR recommendations, initially made in February of 2026, were acted upon by the provider within 30 days as per the facility's policy.2. Record review revealed that Resident ID #29 was admitted to the facility in November of 2022 with diagnoses including, but not limited to, cerebral infarction (stroke) and hyperlipidemia (high cholesterol).Record review revealed a physician's order dated 2/8/2025 for Atorvastatin Calcium (a medication prescribed to treat high cholesterol) 20 milligrams (mg) daily.Record review of an MRR document dated 1/20/2026, revealed a recommendation from the pharmacist to obtain laboratory tests for a baseline and annual liver function test (LFTs) and a lipid panel (a blood test that measures the level of cholesterol and triglycerides in the blood) to monitor therapeutic effects and side effects of atorvastatin.Record review of an MRR document dated 3/25/2026, revealed a repeat recommendation from the pharmacist to obtain laboratory tests for a baseline and annual liver function test (LFTs) and a lipid panel to monitor therapeutic effects and side effects of atorvastatin.Record review of a nursing progress note dated 4/9/2026 at 12:14 PM states in part, Pharmacy rec received and reviewed by [provider]. N.O [new order] for LFT and lipid panel on Monday, then yearly after that.Record review revealed a physician's order dated 4/9/2026 for laboratory tests for LFTs and a lipid panel once on 4/13/2026 and yearly.During a surveyor interview on 4/10/2026 at 10:42 AM with the Physician Assistant, Staff G, he revealed that he was made aware of the above pharmacy recommendations for Resident ID #29 on 4/9/2026 and agreed with the recommendations from 1/20/2026 and 3/25/2026. 3. Record review revealed Resident ID #84 was admitted to the facility in September of 2025 with diagnoses including, but not limited to, major depressive disorder and anxiety.Record review revealed a physician's order dated 2/7/2026 for Trazodone 50 mg daily as needed (prn) for anxiety and agitation.Record review of an MRR document dated 2/19/2026, revealed a recommendation from the pharmacist which states in part, .please evaluate current diagnosis, behaviors and usage pattern.psychotropic [a class of medications that affects behaviors, mood, thoughts, or perceptions] order cannot exceed 14 days.Record review failed to reveal evidence that the above-mentioned MRR was reviewed and acted upon by the provider.During a surveyor interview on 4/10/2026 at 2:16 PM with Nurse Practitioner, Staff N, she revealed that she was not made aware of the MRR dated 2/19/2026 until 4/9/2026, after it was brought to the facility's attention by the surveyor. Additionally, she acknowledged that she approved the pharmacy recommendations.4. Record review revealed Resident ID #107 was admitted to the facility in February of 2025 with diagnoses including, but not limited to, cerebrovascular disease (a group of conditions that affect blood vessels and blood circulation to the brain), hypotension (low blood pressure), and Vitamin D deficiency (low Vitamin D levels).Record review of an MRR document date 2/18/2026 revealed a recommendation from the pharmacist, indicating that the resident is receiving medications that require routine lab work to include, basic metabolic panel (a blood test that checks the body's fluid balance, levels of electrolytes, and kidney function), complete blood count (a group of blood tests that measures the number and size of the different cells in the blood), and Vitamin D (a blood test that measures the level of Vitamin D in the body).Record review failed to reveal evidence that the above-mentioned MRR was reviewed and acted upon by the provider within 30 days as per the facility's policy, until it was brought to the facility's attention by the surveyor on 4/9/2026.During a surveyor interview on 4/10/2026 at 11:07 AM with Physician Assistant, Staff G, he revealed that he was not made aware of the MRR recommendations from 2/18/2026, until 4/9/2026, and that is when he approved the recommendation.

Based on record review and staff interview, the facility failed to complete an annual performance review for every nurse aide (NA) at least once every 12 months, for 5 of 5 NAs' personnel records reviewed, Staff I, J, K, L and M.Findings are as follows:Record review of the following personnel files failed to reveal evidence that an annual performance evaluation was completed for the following NAs:-Staff I, with a hire date of 3/15/2000-Staff J, with a hire date of 11/11/2013-Staff K, with a hire date of 1/21/2025-Staff L, with a hire date of 3/29/2001-Staff M, with a hire date of 7/11/2024During a surveyor interview on 4/10/2026 at 11:15 AM with the Director of Nursing Services, she was unable to provide evidence of performance evaluations for the above-mentioned employees that were completed within the last 12 months.

Based on record review and staff interview, the facility failed to develop, implement, and maintain an effective training program for annual training for existing employees consistent with their expected roles, relative to education per the facility assessment, for 10 of 11 employees reviewed, Staff I, J, K, L, M, T, Y, GG, HH, and II.Findings are as follows:Record review of the Facility Assessment, dated March 2026, states in part, .We utilize Health Stream services for increased/mandatory education on annual and quarterly bases.Staff competencies required.A full ledger of staff-specific courses/competencies can be found in Health Stream.Record review of the facility's Health Stream Annual Education Plan revealed the following required trainings:-Resident rights and abuse prevention-HIPAA (Health Insurance Portability and Accountability Act) and confidentiality-Corporate compliance and ethics-Safe resident handling and transfers-Fall prevention-Emergency preparedness-Skin integrity and pressure injury prevention-Pain assessment and management-Dementia and behaviors-Mental health management-Food safety and sanitation-Nutrition, hydration, and dysphagia care-Effective communication-Culturally competent care-Trauma informed care-Ethics in health careRecord review revealed Unit Manager, Licensed Practical Nurse (LPN), Staff T, was hired on 9/9/2024. A review of his record from 2025 to 2026 failed to reveal evidence that he completed the mandatory required trainings including; resident rights and abuse prevention; corporate compliance and ethics; safe resident handling and transfers; emergency preparedness; skin integrity and pressure injury prevention; pain assessment and management; dementia and behaviors; mental health management; food safety and sanitation; nutrition, hydration, and dysphagia care; effective communication; culturally competent care; trauma informed care; and ethics in health care.Record review revealed LPN, Staff Y, was hired on 5/16/2017. A review of her record from 2025 to 2026 failed to reveal evidence that she completed the mandatory required trainings including: corporate compliance and ethics; mental health management; food safety and sanitation; nutrition, hydration, and dysphagia care; effective communication; culturally competent care; trauma informed care; and ethics in health care.Record review revealed Respiratory Therapist, Staff GG, was hired on 1/20/2022. A review of her record from 2025 to 2026 failed to reveal evidence that she completed the mandatory required trainings including: safe resident handling and transfers; skin integrity and pressure injury prevention; pain assessment and management; dementia and behaviors; food safety and sanitation; nutrition, hydration, and dysphagia care; and culturally competent care.Record review revealed Nursing Assistant (NA), Staff K, was hired on 1/21/2025. A review of his record from 2025 to 2026 failed to reveal evidence that he completed the mandatory required trainings including: resident rights and abuse prevention; corporate compliance and ethics; safe resident handling and transfers; emergency preparedness; skin integrity and pressure injury prevention; pain assessment and management; dementia and behaviors; mental health management; food safety and sanitation; nutrition, hydration, and dysphagia care; effective communication; culturally competent care; trauma informed care; and ethics in health care.Record review revealed NA, Staff M, was hired on 7/11/2024. A review of her record from 2025 to 2026 failed to reveal evidence that she completed the mandatory required trainings including: corporate compliance and ethics; safe resident handling and transfers; skin integrity and pressure injury prevention; pain management; mental health management; nutrition, hydration, and dysphagia care, and effective communication.Record review revealed NA, Staff I, was hired on 3/15/2000. A review of her record from 2025 to 2026 failed to reveal evidence that she completed the mandatory required trainings including: corporate compliance and ethics; safe resident handling and transfers; skin integrity and pressure injury prevention; pain management; mental health management; nutrition, hydration, and dysphagia care.Record review revealed NA, Staff J, was hired on 11/11/2013. A review of her record from 2025 to 2026 failed to reveal evidence that she completed the mandatory required trainings including: corporate compliance and ethics; safe resident handling and transfers; skin integrity and pressure injury prevention; pain assessment and management; mental health management; nutrition, hydration, and dysphagia care.Record review revealed NA, Staff L, was hired on 3/29/2001. A review of her record from 2025 to 2026 failed to reveal evidence that she completed the mandatory required training including: HIPAA and confidentiality; corporate compliance and ethics; safe resident handling and transfers; emergency preparedness; skin integrity and pressure injury prevention; pain management; dementia and behaviors; mental health management; food safety and sanitation; nutrition, hydration, and dysphagia care; effective communication; culturally competent care; trauma informed care; and ethics in health care.Record review revealed Medication Aide (MA), Staff HH, was hired on 1/26/2005. A review of her record from 2025 to 2026 failed to reveal evidence that she completed the mandatory required trainings including: corporate compliance and ethics; safe resident handling and transfers; emergency preparedness; skin integrity and pressure injury prevention; dementia and behaviors; mental health management; food safety and sanitation; nutrition, hydration, and dysphagia care; effective communication; culturally competent care; trauma informed care; and ethics in health care.Record review revealed (MA), Staff II, was hired on 10/27/2003. A review of her record from 2025 to 2026 failed to reveal evidence that she completed the mandatory required trainings including: corporate compliance and ethics; skin integrity and pressure injury prevention; mental health management; and nutrition, hydration, and dysphagia care.During a surveyor interview on 4/10/2026 at 1:11 PM with the Administrator, he indicated that he would expect all trainings that are outlined in the facility assessment to be completed by staff. Additionally, he was unable to provide evidence that the above-mentioned staff received the required annual education and training, per the facility assessment.

Based on clinical record review and staff interviews, the facility failed to ensure that resident records are complete and accurately documented for 1 of 1 resident reviewed for 15-minute checks, Resident ID #9; for 1 of 1 resident reviewed for hand splints, Resident ID #52; and for 1 of 1 resident reviewed with a physician's order to flush his/her Gastrostomy tube (G-tube, a medical device inserted through the abdomen directly into the stomach to provide long-term nutritional support, fluids, and medication) before and after each feeding, Resident ID #71.Findings are as follows:1. Record review revealed Resident ID #9 was readmitted to the facility in January of 2026 with a diagnosis including, but not limited to, dementia with psychotic disturbance.Record review revealed a progress note dated 4/4/2026 which revealed the resident was involved in a physical altercation with another resident, where Resident ID #9 hit him/her on the arm. Further review revealed Resident ID #9 was going to be placed on 15-minute checks over the weekend.Record review revealed a physician's order dated 4/4/2026 for 15-minute checks every shift, until 4/12/2026.Review of a document titled, 15-30-60 Minute Patient Observation Checks, dated 4/4/2026 to 4/5/2026 revealed incomplete documentation on 4/5/2026 from 8:45 AM until 2:45 PM.Review of a document titled, 15-30-60 Minute Patient Observation Checks, dated 4/5/2026 to 4/6/2026 revealed incomplete documentation on 4/6/2026 from 7:15 AM until 10:45 PM.Review of a document titled, 15-30-60 Minute Patient Observation Checks, dated 4/7/2026 to 4/8/2026 revealed incomplete documentation on 4/8/2026 from 7:15 AM until 11:15 AM; this concern was brought to the facility's attention by the surveyor at this time. During a surveyor interview on 4/8/2026 at 11:15 AM, with Licensed Practical Nurse (LPN), Unit Manager, Staff O, she revealed the resident was on 15-minute checks as an intervention, following a physical altercation involving another resident on 4/4/2026. She revealed that the Nursing Assistants complete the documentation on the forms but indicated it is the nurse's responsibility to ensure they are completed. She acknowledged the incomplete documentation on the above-mentioned dates and indicated that she had worked during the day on 4/5/2026 and acknowledged she did not ensure the 15-minute checks were completed as ordered, and documented during her shift, as ordered.During a surveyor interview on 4/8/2026 at 1:14 PM, with the Director of Nursing Services (DNS), she revealed that she would expect the 15-minute checks to be completed in their entirety, as ordered.2. Record review revealed Resident ID #52 was admitted to the facility in March of 2021 with diagnoses including, but not limited to, anoxic brain damage (occurs when the brain is deprived of oxygen) and persistent vegetative state.Review of a care plan focus area initiated on 3/31/2021 revealed Resident ID #52 is dependent upon staff for activities of daily living. An intervention includes, but is not limited to, bilateral splints placed in the morning and removed at night, as tolerated.Record review revealed a physician's order dated 10/12/2022 to apply bilateral hand splints after morning care.Review of the April 2026 Treatment Administration Record revealed the above order to apply the bilateral hand splints was signed off as completed on 4/8/2026 by LPN, Staff H. During a surveyor observation on 4/8/2026 at 11:50 AM, Resident ID #52 did not have his/her hand splints on, as they were observed to be in his/her top drawer.During a surveyor interview immediately following the above observation, Staff H acknowledged that the resident was not wearing his/her bilateral hand splints, as ordered, and acknowledged that she had signed as completed in the TAR, indicating the resident was wearing them. During a surveyor interview on 4/10/2026 at approximately 1:30 PM with the DNS, she revealed that she would expect staff to follow all physician's orders and to sign on treatment orders after they had been completed.3. Record review revealed Resident ID #71 was readmitted to the facility in December of 2024 with a diagnosis including, but not limited to, anoxic brain damage. Further record review revealed the resident has a G-tube.Record review revealed a physician's order dated 1/23/2025, to flush the G-tube with 30 ML of water prior to feeding and flush with 30 ML after each feeding.Review of the February, March, and April 2026 Treatment/Medication Administration Records revealed the above order to flush the resident's G-tube before and after feedings was signed as completed each shift. Further review revealed inconsistent documented fluid totals for every shift, which include 640 ML, 150 ML, and 60 ML.During a surveyor interview on 4/8/2026 at 10:35 AM, with LPN, Staff H, she revealed that she signed the above flushing order on 4/7 and 4/8/2026 and revealed that she documented 60 ML because she calculates 30 ML for each flush and revealed that she was unclear why other staff are documenting other amounts.During a surveyor interview on 4/10/2026 at 9:51 AM, with the DNS, she revealed that she would have expected staff to clarify the physician's order and document accurately.

Based on surveyor observation, clinical record review, and staff interviews, the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for 1 of 2 medication storage rooms observed and 3 of 4 medication carts observed. Findings are as follows:Record review of the facility policy dated [DATE], titled Medication Storage states in part, Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to keep their integrity.the provider pharmacy dispenses medications in containers that meet state and federal labeling requirements.Medications requiring 'refrigeration' .are kept in the refrigerator.Note the date on the label for insulin vials and pens when first opened. Outdated.discontinued medications .are immediately removed from stock.During a surveyor observation on [DATE] at 11:59 AM of the Third-Floor medication storage room, in the presence of Registered Nurse (RN), Staff P, revealed two packets of acetaminophen (pain and fever reducer) suppositories 650 milligram (mg) with expiration dates of 3/2026.During a surveyor interview with Staff P, immediately following the above-mentioned observation, she acknowledged the suppositories were expired.2. During a surveyor observation on [DATE] at 12:09 PM of the One North Low-Side medication cart, in the presence of RN, Staff Q revealed the following:-Humalog 100 unit/milliliter (ml) insulin (a medication prescribed to treat diabetes) vial with an open date of [DATE]. Manufacturer instructions indicate to discard the insulin 28 days after opening.-Solu-Medrol 125 mg vial (a medication prescribed to treat inflammation) without a pharmacy label that indicated a resident identifier.-Lorazepam Intensol (a medication prescribed to treat anxiety) 2 mg/ml with a manufacturer's label indicating to store this medication in the refrigerator.During a surveyor interview with Staff Q immediately following the above-mentioned observations, she acknowledged that the insulin had expired and the Solu-Medrol did not have a resident identifier. Additionally, she acknowledged that the Lorazepam should have been stored in the refrigerator and not in the medication cart.3. During a surveyor observation on [DATE] at 12:33 PM of the one north high-side medication cart, in the presence of Licensed Practical Nurse (LPN), Staff R revealed a bottle of Lorazepam Intensol 2mg/ml with a manufacturer's label indicating to store this medication in the refrigerator.During a surveyor interview with Staff R immediately following the above-mentioned observation, she acknowledged the Lorazepam should have been stored in the refrigerator was revealed.4. During a surveyor observation on [DATE] at 12:42 PM of the One South medication cart in the presence of RN, Staff S, and Unit Manager, LPN, Staff T, revealed the following:-Insulin Lispro 100 unit/ml vial with an opened date of [DATE]. Manufacturer's instructions indicate to discard the insulin 28 days after opening-Lorazepam Intensol 2 mg/ml with a manufacturer's label indicating to store the medication in the refrigerator-Lantus 100 unit/ml insulin pen, opened and not dated. Manufacturer's instructions indicate to discard the insulin 28 days after opening-Morphine Sulfate (a medication prescribed to treat pain) 100 mg/5ml with a discontinued date (d/c) of [DATE]-Tramadol 25 mg (a medication prescribed to treat pain) tablets with a d/c date of [DATE]-Hydrocodone/acetaminophen 10-325 mg (a medication prescribed to treat pain) with a d/c date of [DATE]-Alprazolam 1 mg (a medication prescribed to treat anxiety) with a d/c date of [DATE]-Oxycodone 5mg (a medication prescribed to treat pain) with a d/c date of [DATE]During a surveyor interview with Staff S, she acknowledged that the insulin Lispro should have been discarded, and the Lantus insulin should have been dated when opened. She further acknowledged that the Lorazepam should have been refrigerated. During a subsequent interview with the Staff T, he acknowledged the above-mentioned medications that were discontinued should have been removed from the medication cart and discarded.During a surveyor interview on [DATE] at 1:19 PM with the Director of Nursing Services, she revealed that the discontinued medications should have been removed from the medication cart and destroyed. She further indicated that insulins should be dated when opened and medications that need to be refrigerated should be stored in the refrigerator.

Based on surveyor observation, record review, and staff interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, relative to 3 of 4 kitchenettes.Findings are as follows:1. Review of the 2022 Food Code published by the U.S. Food and Drug Administration (FDA), Section 4-601.11 (C), states in part, .non-contact surfaces of equipment shall be free of an accumulation of .other debris .During a surveyor observation on 4/9/2026 at 11:15 AM, of the One North Unit kitchenette, the microwave was noted to have an accumulation of red/orange dried matter on the ceiling, inside the microwave.During a surveyor interview immediately following the above observation with Dietary Aide, Staff U, she acknowledged that the microwave was dirty and needed to be cleaned.During a surveyor observation on 4/9/2026 at 11:26 AM, of the One South Unit kitchenette, the microwave was noted to have dried splatters and stains of various colors, located on the ceiling and walls inside the microwave.During a surveyor interview, immediately following the above observation with Licensed Practical Nurse, Staff V, she acknowledged the dried splatters inside the microwave and indicated that the microwave needed to be cleaned.2. Review of the 2022 Food Code published by the U.S FDA Section 3-501.17 (A) states in part, .READY -TO-EAT-TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees Celsius or 41 degrees Fahrenheit or below for a maximum of 7 days. The day of preparation shall be counted as Day 1 .Review of an undated facility policy titled, Food Brought in from Outside Sources and Personal Food Storage, states in part, .Foods and beverages brought in from outside sources that require refrigeration or freezing will be labeled with the patient/resident's name and date and stored in the refrigerator/freezer apart from facility food.During a surveyor observation on 4/9/2026 at 11:15 AM, of the One North Unit kitchenette, the following was observed in the refrigerator:-Ten 2-ounce (oz.) cups of pudding and applesauce, eight of which had a use-by date of 4/8, one with a use-by date of 4/1, and one with a use-by date of 4/5-One paper bag containing take-out food, labeled with a resident's name and the date of 4/5During a surveyor interview immediately following the above observations with Staff U, she acknowledged that the pudding and applesauce cups were beyond their use-by dates and needed to be thrown away. She also acknowledged that the bag of take out food had been in the refrigerator beyond three days and needed to be discarded.During a surveyor observation on 4/9/2026 at 11:26 AM, of the One South Unit kitchenette, the following was observed in the refrigerator:-One peanut butter and jelly sandwich with a use-by date of 4/8-One chef's salad with a use-by date of 4/8-Two 2 oz. cups of applesauce, one 2 oz. cup of vanilla pudding, and one 2 oz. cup of chocolate pudding with use-by dates of 4/8During a surveyor interview immediately following the above observation with Licensed Practical Nurse, Staff V, she acknowledged the above food items were beyond their use-by dates and needed to be discarded.During a surveyor observation on 4/9/2026 at 11:40 AM of the Two South Unit kitchenette, the following was observed in the refrigerator:-One peanut butter and jelly sandwich with a use-by date of 4/8-One 96 oz. container of Lactaid whole milk, 2/3 consumed, with an open date of 3/16. Manufacturer's instructions indicate that once opened, it should be consumed within 14 days.-One 96 oz. container of Lactaid whole milk, 2/3 consumed, with an open date of 3/3. The resident's name was illegible in yellow marker and had partially rubbed off.-One 12 oz. container of hickory smoked ham salad, opened and undated. Manufacturer's instructions state to use within 5 to 7 days after opening.-One 22 oz. container of [NAME] Shack rice pudding, opened 3/11, with a use-by date of 5/26. The container of rice pudding was noted to have a sour smell. Manufacturer's instructions state once opened, consume within a few days. If the pudding looks, smells, or tastes off, it should always be discarded.During a surveyor interview on 4/9/2026 at 11:52 AM, Staff U, she acknowledged the above concerns in the Two South kitchenette refrigerator.During a surveyor interview on 4/9/2026 at 12:09 PM with the Assistant Kitchen Manager, Staff W, he acknowledged all of the above concerns and indicated that food items should be dated when opened and thrown out when they are expired.

Based on surveyor observation, clinical record review, and staff interviews, the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infection, relative to maintaining Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities) for 1 of 1 resident observed on EBP, Resident ID #20. Additionally, the facility failed to maintain contact/droplet precautions (an infection control measure that is used when a resident is known or expected to be infected to prevent the spread of germs that can be transmitted through respiratory droplets expelled when a person coughs, sneezes, or speak) for 3 of 3 residents observed on contact/droplet precautions, Resident ID #s 41, 87, and 107.Findings are as follows:Review of the Center for Disease Control and Prevention document titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs) Last Reviewed: August 1, 2023, states in part, Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities .The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents .with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include.Device care or use of a device [i.e that is].feeding tubes.Review of the facility policy titled Infection Control Policies and Procedures dated 12/16/2024, states in part .Signage at the entry of the patient's room shall indicate the type of precautions to use and the type of personal protective equipment [PPE] that is required upon entry.1. Record review revealed Resident ID #20 was admitted to the facility in January of 2024 with a diagnosis including but not limited to anoxic brain damage (occurs when the brain is completely deprived of oxygen, leading to brain cell death). Further review revealed that s/he has a gastrotomy tube (gtube, a medical device inserted through the abdomen directly into the stomach to provide long-term nutritional support, fluids, and medication).During a surveyor observation of signage posted at the resident's doorway on 4/6/2026 at approximately 11:50 AM stated in part, Enhanced Barrier Precautions.Providers and staff must also: wear gloves and a gown for the following High-Contact Resident Care Activities.Device care or use.feeding tube.During a surveyor observation on 4/6/2026 at 11:53 AM, Registered Nurse (RN), Staff X, was observed flushing the resident's G-tube without wearing a gown, as required.During a surveyor interview immediately following the above-mentioned observation with Staff X, she acknowledged that she did not wear a gown when she flushed the resident's G-tube.2. Record review revealed Resident ID #87 was admitted to the facility in September of 2025 with a diagnosis including, but not limited to, acute respiratory failure with hypoxia (a life-threatening emergency when there is not enough oxygen in the blood).Record review of a physician's order dated 4/8/2026 revealed the resident was on contact/droplet precautions for Respiratory Syncytial Virus (RSV; a highly contagious respiratory virus).During a surveyor observation of signage posted at the resident's doorway on 4/8/2026 at approximately 8:00 AM stated in part, Special Contact and Droplet Precautions.wear face shield.upon entering.A. During the medication administration task on 4/8/2026 at 8:13 AM, with RN, Staff Y, she entered Resident ID #87's room to administer his/her medication without a face shield, as indicated on the signage posted.During a surveyor interview immediately following the above-mentioned observation with Staff Y, she acknowledged that she did not wear a face shield prior to entering the room. B. During a surveyor observation on 4/8/2026 at 11:42 AM, Nursing Assistant (NA), Staff Z, was observed in Resident ID #87's room only wearing a gown and mask and not wearing a face shield and gloves, as required. Staff Z then exited the room wearing the same gown, he did not perform hand hygiene, removed gloves from a bin that stored clean PPE outside of the room, and reentered the resident's room without wearing a face shield.During a surveyor interview immediately following the above-mentioned observation with Staff Z, he acknowledged that he did not wear the appropriate PPE, as required.3. Record review revealed Resident ID #41 was admitted to the facility in August of 2025 with a diagnosis including, but not limited to, adult failure to thrive.Record review of a physician's order dated 4/8/2026 revealed the resident was on contact/droplet precautions for RSV.During a surveyor observation of signage posted at the resident's doorway on 4/8/2026 at approximately 9:00 AM stated in part, Special Contact and Droplet Precautions.wear an N95 Respirator, gown, face shield, and gloves.upon entering.During a surveyor observation on 4/8/2026 at 9:03 AM, NA, Staff B, was observed in the resident's room wearing only a mask and gloves and was not wearing a gown and face shield, as indicated on the signage posted.During a surveyor interview immediately following the above-mentioned observation with Staff B, she acknowledged that she did not wear a gown and face shield prior to entering the room. 4. Record review revealed Resident ID #107 was admitted to the facility in February of 2025 with diagnoses including, but not limited to, acute respiratory failure and tracheostomy (a surgically opening created in the neck leading directly into the windpipe to establish an airway using a tube).Record review of a physician's order dated 4/8/2026 revealed the resident is on contact/droplet precautions for RSV.During a surveyor observation of signage posted at the resident's doorway on 4/9/2026 at 8:18 AM revealed s/he is only on Contact Precautions.During a surveyor observation on 4/9/2026 at 9:33 AM in the presence of the Infection Preventionist (IP), she acknowledged the resident was on contact/droplet precautions for RSV and acknowledged the signage posted was inaccurate.During interviews with the Infection Preventionist (IP) on 4/9/2026, at 11:39 AM and 4/10/2026 at approximately 1:00 PM, she stated that staff are expected to adhere to the posted signage at residents' doorways, including donning the required PPE prior to entering any room on precautions. During surveyor interviews on 4/10/2026 at 1:00 PM and 1:30 PM with the Director of Nursing Services, she was unable to provide evidence that infection control practices were maintained by the above staff, as required.

Based on clinical record review and staff interviews, the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed receiving Midodrine (a medication prescribed to treat low blood pressure), Resident ID #13.Findings are as follows:Record review of a facility policy titled, Medication Administration last revised in January of 2023, states in part, .General Guidelines.Medications are administered in accordance with written orders of the prescriber.Record review revealed the resident was re-admitted to the facility in February of 2022 with a diagnosis including, but not limited to, hypotension (low blood pressure).Record review revealed a physician's order dated 2/17/2026 for Midodrine 2.5 milligrams (mg) three times a day for hypotension, with parameters to hold the medication if the systolic blood pressure (SBP; refers to the top number of a blood pressure reading and indicates the pressure in your arteries when your heart contracts) is greater than 110.Record review of the March and April 2026 Medication Administration Records revealed the Midodrine was administered when the resident's SBP was outside of the ordered parameters on the following dates and times:3/1/2026 evening dose, SBP of 1263/2/2026 evening dose, SBP of 1123/3/2026 afternoon dose, SBP of 1263/4/2026 morning dose, SBP of 1123/7/2026 afternoon dose, SBP of 1203/8/2026 afternoon dose, SBP of 112; evening dose, SBP of 1183/13/2026 evening dose, SBP of 1203/14/2026 evening dose, SBP of 1203/15/2026 evening dose, SBP of 1183/20/2026 morning dose, SBP of 1193/24/2026 morning dose, SBP of 1143/25/2026 morning dose, SBP of 1183/28/2026 morning dose, SBP of 1164/6/2026 evening dose, SBP of 118During a surveyor interview on 4/9/2026 at 4:28 PM with Licensed Practical Nurse, Staff O, she acknowledged that the resident was administered Midodrine when his/her SBP was greater than 110 on the above dates and times, indicating the resident received the medication when s/he should not have.During a surveyor interview on 4/10/2026 at 12:52 PM with the Physician Assistant, Staff G, he indicated that he would expect that the Midodrine would be held if the resident's SBP is greater than 110.During a surveyor interview with the Director of Nursing Services on 4/10/2026 at 1:24 PM, she indicated that she would expect the Midodrine to be held on the above-mentioned dates and times, per the physician's order.

Based on clinical record review and staff interviews, the facility failed to ensure that the resident's formulated advance directive would be followed, as there were inconsistencies between the paper medical record and the Electronic Medical Record (EMR), for 1 of 1 resident reviewed who had recently changed his/her code status, Resident ID #4. Findings are as follows:Record review revealed the resident was re-admitted to the facility in April of 2025 with diagnoses including, but not limited to, end stage renal disease (the final stage of kidney failure) and dependence on renal dialysis (a life sustaining treatment that filters waste, toxins, and excess fluids from the blood when the kidneys have failed).Record review of the EMR advance directive banner, indicates a code status of Do Not Resuscitate (DNR)/Comfort Measures Only (CMO). Further review revealed a physician's order dated [DATE] indicating a code status of DNR/CMO. Record review of the most recent Medical Order for Life Sustaining Treatment (MOLST) document, dated [DATE] signed by the provider and the resident, indicates that the resident has a code status to attempt resuscitation/cardiopulmonary resuscitation (CPR). Record review of a provider progress note dated [DATE] indicates that the resident requested to speak to the provider to re-evaluate his/her advance care planning related to his/her code status and that s/he changed his/her mind from wanting to be a DNR to a Full Code. During a surveyor interview on [DATE] at 11:29 AM with the Unit Manager, Licensed Practical Nurse, Staff F, she revealed that the resident's EMR indicates the resident's code status is DNR/CMO. She acknowledged that the most recent signed MOLST indicates to attempt CPR, and that DNR is not indicated. Additionally, she revealed that she would initially refer to the EMR for the resident's code status in the event of an emergency, which would have indicated DNR.During a surveyor interview on [DATE] at 1:12 PM with the Physician Assistant, Staff G, he indicated that he spoke with the resident about his/her code status in February, because the resident had changed his/her mind and no longer wanted a code status of DNR, s/he wanted to be a full code. Staff G acknowledged that the MOLST document dated [DATE], is the resident's most up to date code status.

Based on surveyor observation, clinical record review, and staff interviews, the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to promote wound healing for 1 of 1 resident reviewed with actual pressure ulcers (localized injuries to the skin and/or underlying skin usually over a bony prominence), Resident ID #52.Findings are as follows:Record review revealed the resident was admitted to the facility in March of 2021 with diagnoses including, but not limited to, anoxic brain damage (caused by a lack of oxygen to the brain) and persistent vegetative state. Record review of a nursing progress note dated 4/8/2026 at 5:53 PM, revealed that resident has a new Stage 1 pressure injury to the dorsum (area of the foot on the top surface extending from the ankle to the toes) of his/her right foot.Review of a care plan last revised on 3/5/2026 revealed the resident is at risk for skin breakdown with interventions including, but not limited to, off loading and floating heels with pillows while in bed.Record review of a physician's order dated 5/24/2021 indicated to float heels while in bed. Record review of a physician's order dated 4/8/2026 revealed to offload bilateral heels and feet with pillows at all times, as tolerated, every shift.During surveyor observations on 4/10/2026, at the following times, the resident had his/her heels and feet resting directly on the mattress:-10:16 AM-12:16 PMDuring a surveyor interview on 4/10/2026 at 12:23 PM with the Unit Manager, Staff A, she acknowledged that the resident has a new pressure injury to his/her right foot and s/he has physician's orders to offload his/her heels at all times. During this interview she acknowledged that the resident had his/her feet resting directly on the mattress.During a surveyor interview on 4/10/2026 at approximately 1:30 PM with the Director of Nursing Services, she revealed that she would expect staff to follow all physician's orders.

Based on surveyor observation, clinical record review, and staff interviews, the facility failed to ensure a resident with limited range of motion (ROM) receives appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM for 1 of 2 residents reviewed with contractures (the shortening of muscles, tendons, skin, and nearby soft tissues that cause the joints to become very stiff, which prevents normal movement), Resident ID #52.Findings are as follows:Record review revealed Resident ID #52 was admitted to the facility in March of 2021 with diagnoses including, but not limited to, anoxic brain damage (caused by a lack of oxygen to the brain) and persistent vegetative state. Record review of a Minimum Data Set Assessment (MDS) dated [DATE] revealed the resident was in a persistent vegetative state with no discernible consciousness. Further review revealed the resident had impaired range of motion to both of his/her upper extremities. Additional review revealed that the resident is dependent on staff for activities of daily living (ADLs). Record review of an Occupational Therapy (OT) Discharge summary dated [DATE], revealed the resident has contractures to his/her right and left hands. Discharge recommendations include a splint/brace to both hands after morning care.Record review of a physician's order dated 10/13/2022 revealed bilateral hand splints to be applied after morning care.Review of a care plan last revised on 4/19/2022 revealed the resident is dependent on staff for ADLs with interventions including, but not limited to, bilateral splints to be applied in the morning and removed in the afternoon/evening as tolerated.During surveyor observations on the following dates and times, the resident did not have his/her bilateral hand splints on:-4/6/2026 at 9:58 AM-4/6/2026 at 11:59 AM-4/7/2026 at 8:58 AM -4/7/2026 at 9:58 AM -4/8/2026 at 9:58 AM -4/8/2026 at 10:59 AM -4/8/2026 at 11:50 AMDuring the above surveyor observations from 4/6/2026 through 4/8/2026 the resident's bilateral hand splints could be seen in the top drawer of his/her nightstand. Record review of the April 2026 Treatment Administration Record revealed an order dated 10/13/2022 for bilateral hand splints to be applied after morning care. This order was signed by staff as being completed daily from 4/1/2026 through 4/8/2026.During a surveyor interview on 4/8/2026 at 11:53 AM with Licensed Practical Nurse, Staff H, she acknowledged that the resident was not wearing his/her bilateral hand splints. She further acknowledged that she signed that the treatment was completed.Record review revealed a new physician's order dated 4/9/2026 for bilateral hand splints to be applied after morning care as tolerated in the morning. This order was created after the above observations and interview.During a surveyor interview on 4/10/2026 at approximately 1:30 PM with the Director of Nursing Service, she revealed that she would expect staff to follow all physician's orders and to sign treatment orders after the treatment was completed.

Based on record review and staff interview, the facility failed to ensure that each resident was given a written accounting of his/her deposits, withdrawals, and balances, at least quarterly for 6 of 6 residents reviewed, Resident ID #s 14, 55, 57, 71, 74, and 86.Findings are as follows:Record of a facility document titled Resident Fund Management Service balance report as of 4/8/2026, revealed that the facility holds funds for Resident ID #s 14, 55, 57, 71, 74, and 86.Record review failed to reveal evidence quarterly statements were provided to Resident ID #s 14, 55, 57, 71, 74, and 86.During a surveyor interview on 4/8/2026 at 10:19 AM, with the Regional Business Office Assistant, she was unable to provide evidence of a written accounting of the above residents' deposits, withdrawals, and balances at least quarterly, per the regulation.During a surveyor interview on 4/10/2026 at 12:40 PM, with the Administrator, he was unable to provide evidence that the facility provided quarterly statements for the above-mentioned residents within the last four quarters, as required.

Based on record review and staff interview, the facility failed to notify each resident, or resident representative, that receives Medicaid benefits when the amount in the resident's account reaches $200 less than the Social Security Income (SSI) resource limit for 2 of 2 residents reviewed with over $4000 in personal needs funds handled by the facility, Resident ID #s 14 and 74. Findings are as follows:Record review of Title 210-Executive Office of Health and Human Services, Chapter 50-Medicaid Long-Term Services and Supports (LTSS) under section 2.4 (G) of the Uniform Accountability Procedures for Title XIX Resident Personal Needs Funds in Community Nursing Facilities, ICF/DD Facilities, and Assisted Living Residences requires that the facility shall: .(10) The nursing facility must notify the resident in writing when his/her balance reaches $200.00 less than the resource eligibility guideline, that Medicaid eligibility is jeopardized if the account exceeds the guideline [4,000] .Review of a facility document titled, Trial Balance .Balances as of 4/8/2026 for the following residents states in part:-Resident ID #14 has a current balance of $5,522.21.-Resident ID #74 has a current balance of $4,118.71.During a surveyor interview on 4/8/2026 at 10:19 AM, with the Regional Business Office Assistant, she was unable to provide evidence that Resident ID #s 14 and 74 were notified in writing when their account balances reached $200 less than the SSI Medicaid eligibility resource limit ($4,000).

Based on record review and staff interview, it has been determined that the facility failed to have sufficient nursing staff with the appropriate skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident relative to the medication verification process for the readmission of Resident ID #1 that involved six staff members, Staff A, B, C, E, the Assistant Director of Nursing Services (ADNS), and the resident's physician, that resulted in a significant medication error for Resident # 1. Additionally, the facility failed to have nursing staff with the appropriate skills set regarding the care and treatment of Resident ID #1 after s/he was found unresponsive on the floor. Further, the facility failed to have nursing staff with the appropriate skills set to provide effective cardiopulmonary resuscitation (CPR) consistent with basic life support protocols for a resident who was found without a pulse or respirations, Resident ID #3Findings are as follows:Review of the Facility assessment dated [DATE]-2026 revealed that the facility requires mandatory education and training/competencies based on job title including accident prevention/staff and resident safety as well as ventilator (a machine that assists with breathing) and tracheostomy (a surgical procedure to create an opening through the neck into the windpipe to facilitate breathing) management. Additionally, required services include respiratory, physician, and skilled nursing services, as well as medication management.1. Record review revealed Resident ID #3 was admitted to the facility in August of 2025 with diagnoses including, but not limited to, acute and chronic respiratory failure with hypoxia (low levels of oxygen in the blood), and a tracheostomy.Record review revealed that Resident ID #3 was a full code indicating that s/he wishes to receive life saving measures including CPR, which consists of chest compressions and rescue breaths, if required, in the event of a medical emergency.Review of a progress note dated [DATE] at 7:49 AM, authored by Licensed Practical Nurse (LPN), Staff G, revealed that Resident ID #3 was pulseless and not breathing. A code was called, CPR was initiated by Respiratory Therapist (RT), Staff D, Registered Nurse (RN), Staff E, and himself (Staff G). Further, rescue personnel arrived approximately 10 minutes after they were called and had resumed CPR efforts.Review of the emergency personnel report dated [DATE] revealed that they arrived on scene to find the facility staff performing CPR on Resident ID #3 while s/he was in bed. Emergency personnel noted that facility staff were only performing chest compressions. Further, rescue personnel began providing Resident ID #3 with 15 liters (L) of oxygen and rescue breaths at 12 breaths per minute (bpm) via an Ambu bag (resuscitation bag), and s/he was subsequently transferred to the hospital.Record review revealed that the resident later died at the hospital.According to an article titled, The optimal surface for delivery of CPR: An updated systematic review and meta-analysis of the National Library of Medicine dated July of 2024 states in part, .(CPR) is considered a crucial first step in managing a cardiac arrest as chest compressions play a vital role in maintaining hemoperfusion [blood flow] to the brain, heart and other vital organs. The International Liaison Committee on Resuscitation (ILCOR) and its member organizations emphasize high-quality chest compressions as part of the cardiac arrest chain of survival with current guidelines recommending chest compression depth of 5-6 cm [centimeters] in children and adults.Performing adequate chest compressions on soft surfaces, such as a mattress, poses challenges as it can compress both the chest and surface itself.up to 57 [percent] of the compression force may be absorbed by the mattress resulting in insufficient compression depth and increased provider fatigue.The need for additional force to counteract the mattress's absorption may further exacerbate provider fatigue. The insertion of backboards.or the movement of patients to the floor have been proposed to counter the impact of soft surfaces.Additionally, review of a facility policy titled, PROCEDURE: OXYGEN: RESUSCITATION BAG (AMBU BAG), last revised [DATE] states in part, .For a patient who has a tracheostomy.attach the resuscitation bag directly to the tracheostomy tube.Ventilate by squeezing the bag with sufficient force to cause the chest to rise.Squeeze the bag once every five to six seconds [equivalent to 10-12 bpm].During a surveyor interview on [DATE] at 10:18 AM with LPN, Staff G, he revealed that Resident ID #3 was found unresponsive on the toilet by another staff member who called for help. He further revealed that he and other staff members transferred the resident from the toilet to his/her bed and began performing CPR. Additionally, he indicated that a backboard was not used at any point during CPR. During a surveyor interview on [DATE] at 3:23 PM with RT, Staff D, he revealed that he was the only staff member that used the Ambu bag during CPR until rescue personnel arrived on scene and resumed CPR efforts. He further revealed that he set the oxygen flow rate to 15 L and delivered only three bpm via the Ambu bag, instead of the 10-12 bpm as per the facility's Ambu bag procedure policy, and consistent with basic life support protocols. When the surveyor inquired further, Staff D changed his story and indicated that he did not provide rescue breaths with the Ambu bag for the duration of CPR and had delegated that responsibility to another staff member because he had taken over performing chest compressions but was unable to recall the identity of the staff member he handed the Ambu bag to. Additionally, he revealed that he was not actively performing rescue breaths when rescue personnel arrived on scene.During a surveyor interview on [DATE] at approximately 9:15 AM with the Respiratory Therapy Director, she revealed that she would expect 10 bpm to be administered via Ambu bag while CPR is being performed. Further, she would have expected that Staff D would have remained performing rescue breaths for the duration of CPR until rescue personnel arrived and not to have delegated rescue breaths to another staff because he is the RT and that is his area of specialty.During surveyor interviews on [DATE] at 2:20 PM and [DATE] at 10:32 AM with the Director of Nursing Services (DNS), he revealed that he would have expected staff to have moved Resident ID #3 from the toilet to the floor to perform CPR and for him/her to receive rescue breaths for the duration of CPR at a rate consistent with the facility's procedure and basic life support protocols.2. Review of a facility reported incident submitted to the Rhode Island Department of Health on [DATE] revealed that Resident ID #1 had experienced a fall on [DATE] and was transferred to an acute care hospital. Additionally, the resident subsequently died.Record review revealed Resident ID #1 was readmitted to the facility in October of 2025 with a diagnosis including, but not limited to, heart failure, pulmonary hypertension (a condition where the blood pressure in the arteries of the lung is high), and chronic kidney disease.Review of the progress notes revealed Resident ID #1 was transferred to an acute care hospital and was admitted for congestive heart failure exacerbation and respiratory distress on [DATE] and was later readmitted to the facility on [DATE].2a. Review of a facility policy titled, .Medication Reconciliation. states in part, .for patients admitted from the hospital: obtain and review copies of Medication Administration Records [MAR], transfer forms, and physician's order sheets.verify MAR/TAR [Treatment Administration Record] information with transfer forms.Review of a hospital document titled, Continuity of care adult discharge, dated [DATE], revealed that the resident returned with an order for Metolazone 5 milligrams (mg) by mouth, three times a week.Review of a physician's order dated [DATE], entered by RN, Staff A, revealed the order for Metolazone 5 mg was incorrectly transcribed to be given three times daily instead of three times a week.Record review of a pharmacy document revealed that on [DATE], the pharmacy attempted to contact the facility twice regarding the Metolazone order to confirm frequency as it is usually ordered three times a week. Further, it indicates that only three tablets would be sent. Additionally, a pharmacy representative had spoken with agency RN, Staff B, on the following day, [DATE] at 4:53 PM, indicating the pharmacist expressed concerns indicating that the Metolazone order was incorrect. Further, the document revealed that Staff B instructed the pharmacy to send the Metolazone and that she will call the provider to verify the medication order.During a surveyor interview on [DATE] at approximately 2:00 PM with Staff B, she acknowledged speaking with a pharmacist on [DATE] regarding Resident ID #1's Metolazone order. She revealed that she was supposed to verify the medication order with a provider but had forgotten to do so.Review of a document titled, admission CHECKLIST dated [DATE] for Resident ID #1 revealed that the document is a mandatory checklist that each shift is required to use to address all elements within 24 hours to ensure 100% compliance with the admission process. Included on the checklist is a medication orders section that indicates to reconcile medications. The last page of the document contained a signature space for the admitting nurse, a second nurse check, and a nurse during the clinical meeting review. Additionally, the document was signed by RN, Staff A (the admitting nurse), RN, Staff E (second nurse check), the ADNS and LPN, Staff C (clinical meeting review nurses).Record review failed to reveal evidence that Staff A, Staff E, Staff C, or the ADNS identified the Metolazone order transcription error upon completing the second and third medication reconciliation checks.During a surveyor interview on [DATE] at 1:58 PM with Staff A, she revealed that she completed the resident's readmission on [DATE] and transcribed his/her medication orders. She acknowledged that the hospital continuity of care form indicated the resident was to start Metolazone 5 mg three times a week, but she incorrectly transcribed the order to administer Metolazone 5 mg three times a day. Additionally, she indicated that two additional chart/medication verification checks are supposed to be completed after the admission is completed by the oncoming nurse and management.Review of written statement dated [DATE], authored by Staff E, revealed that she completed the resident's chart check including the medication verification, however, the check failed to identify the Metolazone medication transcription error that was incorrectly entered by Staff A.During surveyor interviews on [DATE] at 3:05 PM with the ADNS and LPN, Staff C, they acknowledged that they both completed the resident's final chart check and acknowledged that they failed to identify the Metolazone transcription error. Additionally, Staff C revealed that when the ADNS was reading medications aloud from the facility's system, she answered, yes without verifying orders with the continuity of care form document to ensure that medication orders were accurately transcribed into the facility's system.Additional review of a progress note authored by Resident ID #1's physician dated [DATE], revealed that he saw the resident that day at approximately 5:00 PM following his/her readmission to the facility. The note indicated that s/he was started on Metolazone 5 mg three times a week.Record review failed to reveal evidence that Resident ID #1's physician identified the Metolazone order transcription error upon seeing the resident and reviewing his/her medical record.Review of the [DATE] MAR revealed that Resident ID #1 had received Metolazone 5 mg three times on both 10/10 and 10/11, and once on [DATE], indicating that s/he received a total of seven doses within three days despite having communication with the pharmacy questioning the medication order, second and third verification checks being completed, and the provider having reviewed Resident ID #1's medical record on [DATE].During a surveyor interview on [DATE] at 11:03 AM with the resident's physician, he revealed that he had seen the resident at approximately 5:00 PM on [DATE], the day after his/her readmission. He indicated that he reviewed the resident's medical record, the discharge medications which included the Metolazone 5 mg three times a week but failed to identify the transcription error. He further revealed that he does not reconcile the medication orders in the facility's system with the hospital continuity of care form because it is not feasible. Additionally, he revealed that it is the nursing staff's responsibility and that is why they have a medication verification checklist in place. Furthermore, he indicated that the facility needs to provide more education to the nurses related to this concern.During a surveyor interview on [DATE] at 12:05 PM with the DNS, he revealed that he would have expected that the medication transcription error to have been identified during the medication reconciliation process and that RN, Staff B would have notified the provider immediately after speaking with the pharmacist regarding the medication order.2b. According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.Review of a care plan dated [DATE] revealed a focus area that Resident ID #1 is at risk for dehydration related to medications including diuretics. The plan included interventions to administer medications as ordered and to monitor for signs and symptoms of dehydration including, but not limited to, orthostatic hypotension. Review of a progress note of a telehealth consult with a provider that occurred on [DATE] revealed, a nurse had contacted a provider indicating that a medication error had occurred regarding Resident ID #1's Metolazone 5 mg order that was intended to be given three times a week, but instead was entered to be given three times a day, and that s/he had received the medication three times on both 10/10 and 10/11, and once on [DATE]. New orders were given to discontinue the Metolazone 5 mg three times a day, hold Metolazone until assessed by the in house provider, obtain orthostatic vital signs (measurement of blood pressure and heart rate taken in different positions including, lying, sitting, and standing, to assess for changes in cardiovascular function when a person stands up) now, an ultrasound of the heart, lab work, and to call back with the results.Review of the prescriber information packet for Metolazone revealed the following adverse/side effects: orthostatic hypotension (a condition characterized by a sudden drop in blood pressure when standing up, leading to symptoms like fainting and dizziness), syncope (a temporary loss of consciousness due to reduced blood flow to the brain), dizziness/lightheadedness, drowsiness, fatigue, and weakness.Review of a progress note dated [DATE] at 5:25 PM revealed, the resident was found by the lab technician face down on the floor of his/her room, unresponsive, and actively bleeding. Further, his/her blood pressure was noted to be 78/29 (a normal blood pressure reading is 120/80 and a low blood pressure reading is considered anything below 90/60. Low blood pressure has the potential to cause dizziness, fainting, confusion, and/or nausea) at that time. Additionally, the resident was transferred to an acute care hospital via rescue and subsequently died.Record review failed to reveal evidence that orthostatic vital signs were obtained prior to Resident ID #1 being found unresponsive on the floor approximately 3.5 hours after the provider gave the new order.During a surveyor interview on [DATE] at 12:00 PM with LPN, Staff F, she revealed that she identified the medication error regarding the resident's Metolazone on [DATE] at approximately 2:00 PM and notified a provider, prior to the resident's unwitnessed fall. She revealed that the provider ordered blood work, a blood pressure reading to be obtained, and an ultrasound of the heart. Staff F further revealed that the resident appeared more sleepy. Additionally, she revealed that she did not obtain the orthostatic vital signs on the resident because she was entering all of the provider's new orders into the system, so she delegated that task to the oncoming nurse, agency RN, Staff H.During a surveyor interview on [DATE] at 2:11 PM with Staff H, she revealed that she had taken report from Staff F at approximately 4:15 PM but was never informed that a medication error had occurred for Resident ID #1. She indicated that it was not until she overheard Staff F discussing the medication error with the Nursing Supervisor, LPN, Staff I, that she was aware of the medication error and that orthostatic vital signs were ordered by the provider. Additionally, she revealed it was at this time that the lab technician, who had come to draw the resident's blood, found him/her on the floor and yelled for help.During a surveyor interview on [DATE] at 10:24 AM with Staff I, she revealed that she was not informed of the medication error until she had been paged to Resident ID #1's unit when Staff F informed her, which was approximately the same time the lab technician found the resident on the floor. Staff I revealed that had she been made aware of the medication error she would have stayed with the resident to prevent a fall from happening, because the resident is a fall risk and oftentimes attempts to transfer him/herself independently.During a surveyor interview on [DATE] at 12:05 PM with DNS, he revealed that he would have expected staff to have immediately assessed Resident ID #1's orthostatic vital signs once the provider had given the order.2c. Record review revealed that Resident ID #1 was a full code indicating that s/he wishes to receive life saving measures including CPR, which consists of chest compressions and rescue breaths, if required, in the event of a medical emergency.Review of the Emergency Medical Services (EMS) documentation dated [DATE] revealed when EMS arrived on the scene, the resident was found face down on the floor in a large pool of blood. The report noted that facility staff were attempting to apply a nasal cannula for oxygen delivery, reaching beneath the resident's head without confirming airway patency or assessing for respirations. Additionally, EMS rolled the resident on his/her back and their primary assessment revealed s/he had extensive facial trauma, a large hematoma (a collection of blood outside of the blood vessels) to the forehead, swelling around both eyes, and significant bleeding of the mouth and nose that had visible clots. More importantly, the resident was found to not be breathing, and EMS inserted an artificial airway device and began providing rescue breaths via an Ambu bag (resuscitation bag).During a surveyor interview on [DATE] at approximately 2:25 PM with RT, Staff J, she revealed that she observed Resident ID #1 lying in his/her bed at approximately 5:00 PM. She further revealed that at approximately 5:30 PM, she observed staff rushing towards Resident ID #1's room, so she followed. She entered the resident's room to find agency RN, Staff K, crouched down by the resident, who was observed to be lying face down on the floor, unresponsive, in a large pool of blood. She further revealed that Staff K was calling for the crash cart and more staff assistance. Staff J indicated that she began assessing the resident, who remained face down, and noted his/her respirations to be approximately 10 per minute. She indicated that his/her respiratory rate began to decrease to approximately six per minute after five minutes had elapsed. Additionally, she revealed that at that time, she wanted to reposition the resident on his/her back to re-evaluate him/her but was instructed by Staff K not to move the resident.During a surveyor interview on [DATE] at approximately 4:35 PM with Staff K, she revealed that it was the facility's policy to not move any residents following an unwitnessed fall with a head injury, and to wait for EMS to arrive. She revealed that while awaiting the arrival of EMS, the resident's breathing changed, becoming slower and shallower, around four to five breaths per minute. When the surveyor inquired about re-evaluating the resident when his/her condition was confirmed to be deteriorating, she revealed that she did not re-evaluate the resident's condition nor implement any interventions including assessing his/her airway patency or the source of the bleeding, despite the resident's worsening condition. She further revealed that the resident remained face down on the floor until the arrival of EMS.During surveyor interviews on [DATE] at 11:03 AM and 1:47 PM with Resident ID #1's physician, he revealed that he would have expected nursing staff to have stabilized the resident's head and neck and log-rolled him/her on his/her side or back to evaluate and re-evaluate the resident's condition in anticipation of providing CPR, if needed.During a surveyor interview on [DATE] at 12:05 PM with the DNS, he revealed that he would have expected staff to have safely repositioned the resident to re-evaluate his/her condition if his/her condition was noted to be worsening. He was unable to provide evidence that the facility maintained competent nursing staff with the appropriate skills set to properly care for Resident ID #1 following a traumatic fall.The facility's failure to ensure that they maintain sufficient nursing staff with the appropriate skill sets to provide nursing and related services to assure resident safety relative to the medication verification process, resident assessment during an emergency situation, and providing effective CPR consistent with basic life support protocols, had the potential to cause serious injury, harm, impairment, or death for Resident ID #1 and #3, who both subsequently died.Cross reference F 678 and F 760

Based on record review and staff interview, it has been determined that the facility failed to provide effective cardiopulmonary resuscitation (CPR) consistent with basic life support protocols to a resident who was found without a pulse or respirations, Resident ID #3. 1. Record review revealed Resident ID #3 was admitted to the facility in August of 2025 with diagnoses including, but not limited to, acute and chronic respiratory failure with hypoxia (low levels of oxygen in the blood) and a tracheostomy (a surgical procedure to create an opening through the neck into the windpipe to facilitate breathing).Record review revealed that Resident ID #3 was a full code indicating that s/he wishes to receive life saving measures including CPR, which consists of chest compressions and rescue breaths, if required, in the event of a medical emergency.Review of a progress note dated [DATE] at 7:10 AM, authored by Respiratory Therapist (RT), Staff D, revealed that at approximately 5:45 AM, Resident ID #3 was found unresponsive on the toilet by another staff member who called for help. Additionally, Staff D, rushed into the room and immediately started providing rescue breaths via the Ambu bag (resuscitation bag) as Registered Nurse (RN), Staff E, was performing chest compressions. Further, an Automated External Defibrillator (AED, a portable device used to treat a person whose heart has suddenly stopped working) was applied.Additional review of the progress notes revealed a note dated [DATE] at 7:49 AM, authored by Licensed Practical Nurse (LPN), Staff G, revealed that Resident ID #3 was pulseless and not breathing. A code was called, and CPR was initiated by Staff D, Staff E, and himself (Staff G). Further, rescue personnel arrived approximately 10 minutes after they were called and had resumed CPR efforts.Review of the emergency personnel report (EPR) dated [DATE] revealed that they were dispatched to the facility at approximately 6:10 AM and arrived on scene to find Resident ID #3 in his/her bed, unresponsive and cyanotic [a blue/purple discoloration of the skin and mucous membranes due to insufficient oxygenation of the blood]. Rescue personnel noted the facility staff performing CPR on Resident ID #3 but were only conducting chest compressions. The documentation failed to indicate that Resident ID #3 had been receiving supplemental oxygen and rescue breaths via an Ambu bag prior to their arrival. Additionally, the EPR revealed rescue personnel began providing Resident ID #3 with 15 liters (L) of oxygen and rescue breaths at 12 breaths per minute (bpm) via an Ambu bag, and s/he was subsequently transferred to the hospital.Review of the hospital documentation dated [DATE] revealed that Resident ID #3 arrived at the Emergency Department at 7:12 AM and was pronounced dead at 7:21 AM. The documentation indicates that rescue personnel informed the hospital staff that the facility staff were performing CPR to the resident while s/he was in bed.1a. According to an article titled, The optimal surface for delivery of CPR: An updated systematic review and meta-analysis of the National Library of Medicine dated July of 2024 states in part, .(CPR) is considered a crucial first step in managing a cardiac arrest as chest compressions play a vital role in maintaining hemoperfusion [blood flow] to the brain, heart and other vital organs. The International Liaison Committee on Resuscitation (ILCOR) and its member organizations emphasize high-quality chest compressions as part of the cardiac arrest chain of survival with current guidelines recommending chest compression depth of 5-6 cm [centimeters] in children and adults.Performing adequate chest compressions on soft surfaces, such as a mattress, poses challenges as it can compress both the chest and surface itself.up to 57 [percent] of the compression force may be absorbed by the mattress resulting in insufficient compression depth and increased provider fatigue.The need for additional force to counteract the mattress's absorption may further exacerbate provider fatigue. The insertion of backboards.or the movement of patients to the floor have been proposed to counter the impact of soft surfaces.During a surveyor interview on [DATE] at 10:18 AM with LPN, Staff G, he revealed when Resident ID #3 was found unresponsive on the toilet, he and other staff members transferred the resident from the toilet to his/her bed and began performing chest compressions. Additionally, he further revealed that they did not use a backboard at any point when they were performing CPR. During a surveyor interview on [DATE] at 2:20 PM with the Director of Nursing Services (DNS), in the presence of the Administrator, he revealed that he would have expected that staff would have moved Resident ID #3 from the toilet to the floor to perform CPR instead of transferring him/her to a bed. Additionally, he revealed that if CPR efforts were performed while the resident was in bed, he would have expected a backboard to have been used.1b. Review of a facility policy titled, PROCEDURE: OXYGEN: RESUSCITATION BAG (AMBU BAG) last revised [DATE] states in part, .For a patient who has a tracheostomy.attach the resuscitation bag directly to the tracheostomy tube.Ventilate by squeezing the bag with sufficient force to cause the chest to rise.Squeeze the bag once every five to six seconds [equivalent to 10-12 bpm].During a surveyor interview on [DATE] at 10:18 AM with Staff G, he revealed that the RT, Staff D, was the only staff member that had been providing the resident rescue breaths with an Ambu bag while CPR was being performed.During a surveyor interview on [DATE] at 3:23 PM with Staff D, when initially asked what staff members had used the Ambu bag to deliver rescue breaths to Resident ID #3 during CPR, he revealed that he was the only staff member that used the Ambu bag during CPR until the rescue personnel arrived on scene and resumed CPR efforts. He further revealed that he set the oxygen flow rate to 15 L and delivered only three bpm via the Ambu bag, instead of the 10-12 bpm as per the facility's Ambu bag procedure policy, and consistent with basic life support protocols. When the surveyor inquired further, Staff D changed his story and indicated that he did not provide rescue breaths with the Ambu bag for the duration of CPR, and had delegated that responsibility to another staff member, who he was unable to identify, because he had taken over performing chest compressions. Additionally, he revealed that he was not actively performing rescue breaths with the Ambu bag when rescue personnel arrived on scene because he had exited the room to obtain a piece of respiratory equipment and was unsure who was providing rescue breaths at that time.During a surveyor interview on [DATE] at approximately 9:15 AM with the Respiratory Therapy Director, she revealed that she would expect 10 bpm to be administered via Ambu bag while CPR is being performed. She further revealed that she would have expected that Staff D would have continued to provide rescue breaths for the duration of CPR, until rescue personnel have taken over CPR efforts, and that Staff D would not have stopped providing rescue breaths at any point nor delegated that responsibility to any other personnel.During a surveyor interview on [DATE] at 10:32 AM with the DNS, he revealed that he would expect that Staff D would have provided oxygen and rescue breaths via an Ambu bag for the duration of CPR and at a rate of more than three bpm. Additionally, he was unable to provide evidence that the facility provided effective CPR consistent with basic life support protocols for Resident ID #3.The facility's failure to perform effective CPR had the potential to cause serious injury, harm, impairment, or death for Resident ID #3, who was pronounced dead minutes after arriving to the hospital.Cross reference F 726

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed who received Metolazone (a diuretic medication prescribed to treat fluid retention by increasing urine production) not as intended, Resident ID #1. Findings are as follows:Record review of a facility reported incident submitted to the Rhode Island Department of Health on [DATE] revealed that Resident ID #1 had experienced a fall on [DATE] and was transferred to an acute care hospital. The resident subsequently died.Record review revealed Resident ID #1 was readmitted to the facility in October of 2025 with a diagnosis including, but not limited to, heart failure, pulmonary hypertension (a condition where the blood pressure in the arteries of the lung is high), and chronic kidney disease.Review of a care plan dated [DATE] revealed a focus area that s/he is at risk for dehydration related to medications including diuretics with interventions that include to administer medications as ordered.Review of the progress notes revealed the resident was transferred to an acute care hospital and was admitted for congestive heart failure exacerbation and respiratory distress on [DATE] and was later readmitted to the facility on [DATE].Review of a facility policy titled, .Medication Errors. states in part, .[facility] shall ensure medications will be administered.according to prescriber's orders.Review of a hospital document titled, Continuity of care adult discharge dated [DATE], revealed that the resident returned with an order for Metolazone 5 milligrams (mg) by mouth three times a week. Additionally, the resident was to also continue on a fluid restriction, medications to lower his/her blood pressure, and another diuretic medication.Review of the prescriber information packet for Metolazone revealed the following adverse/side effects: orthostatic hypotension (a condition characterized by a sudden drop in blood pressure when standing up, leading to symptoms like fainting and dizziness), syncope (a temporary loss of consciousness due to reduced blood flow to the brain), dizziness/lightheadedness, drowsiness, fatigue, and weakness.Review of a physician's order dated [DATE], entered by Registered Nurse, Staff A, revealed the order for Metolazone 5 mg was incorrectly transcribed to be given three times daily instead of three times a week.Review of the [DATE] Medication Administration Record revealed that Resident ID #1 had received Metolazone 5 mg three times on both 10/10 and 10/11, and once on 10/12, indicating that s/he received a total of seven doses within three days instead of the two doses, as ordered.Review of the nursing progress notes revealed the following:-[DATE] at 11:00 PM: The resident's Metolazone 5 mg order was incorrectly transcribed resulting in the resident receiving his/her Metolazone 5 mg three times on 10/10 and [DATE]. Additionally, the note indicates that the resident's physical exam revealed that s/he appeared fatigued.-[DATE] at 7:42 AM: The resident's blood pressure had been obtained and was noted to be 102/58 (a normal blood pressure reading is 120/80 and a low blood pressure reading is considered anything below 90/60. Low blood pressure has the potential to cause dizziness, fainting, confusion, and/or nausea).-[DATE] revealed that on [DATE] at approximately 5:25 PM, the resident was found on the floor of his/her room unresponsive and bleeding from his/her face. His/her blood pressure was noted to be 78/29 at that time. Additionally, the resident was transferred to an acute care hospital via rescue and subsequently died.Review of the Emergency Medical Services (EMS) documentation dated [DATE] revealed when EMS arrived on scene, the resident was found face down on the floor in a large pool of blood. Further, the report noted that facility staff were attempting to apply a nasal cannula for oxygen delivery, reaching beneath the resident's head without confirming airway patency or assessing for respirations. EMS rolled the resident on his/her back and their primary assessment revealed s/he had extensive facial trauma, a large hematoma (a collection of blood outside of the blood vessels) to the forehead, swelling around both eyes, and significant bleeding of the mouth and nose that had visible clots. More importantly, the resident was found to not be breathing, and EMS inserted an artificial airway device and began providing rescue breaths via an Ambu bag (resuscitation bag).During a surveyor interview on [DATE] at 12:00 PM with Licensed Practical Nurse, Staff F, she revealed that she identified the medication error regarding the resident's Metolazone and notified a provider, prior to the resident's unwitnessed fall. She further revealed that the provider had ordered blood work, a blood pressure reading to be obtained, and an ultrasound of the heart. Additionally, she revealed that the resident appeared more sleepy.During a surveyor interview on [DATE] at approximately 2:25 PM with Respiratory Therapist, Staff J, she revealed that she entered the resident's room after she witnessed staff rushing in to find the resident face down on the floor in a pool of blood. She further revealed that the resident receives continuous oxygen via a nasal cannula (oxygen tubing), and that the resident must have fallen so forcefully, it caused the oxygen tubing to snap and break. Additionally, she revealed that the resident must have fallen as soon as s/he stood up based on how s/he was found on the floor.During a surveyor interview on [DATE] at 1:58 PM with RN, Staff A, she acknowledged that she was the nurse that incorrectly transcribed the Metolazone order that was entered on [DATE] to be given three times a day instead of three times a week. Additionally, Staff A acknowledged that the hospital paperwork indicated to administer Metolazone 5 mg three times a week and revealed that the provider had approved that order.During a surveyor interview on [DATE] at 1:15 PM with the Director of Nursing Services, he acknowledged that the resident's Metolazone 5 mg order was incorrectly transcribed resulting in the resident receiving the medication three times on 10/10 and 10/11, and once on [DATE] when s/he should have received the Metolazone 5 mg three times a week. He was unable to provide evidence that the facility ensured that residents are free of any significant medication errors.During a surveyor interview on [DATE] at 12:33 PM with a Registered Pharmacist, she revealed that Metolazone 5 mg three times a week is a typical prescribed dose and frequency. Additionally, she revealed that adverse/side effects of Metolazone use has the potential to increase the diuretic effect that could result in dehydration, as well as lethargy, dizziness, orthostatic hypotension, fainting, and syncopal episodes.The facility's failure to ensure that residents are free of any significant medication errors had the potential to cause serious injury, harm, impairment, or death for Resident ID #1, who subsequently died at the hospital.Cross reference F 726

Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident environment remains as free of accident hazards relative to falls for 1 of 3 residents reviewed, Resident ID #5. The facility failed to implement the resident's care plan, leading directly to an accident and injury to resident #5, who sustained a left distal tibia (large shinbone) and fibula (smaller shinbone) fracture.Findings are as follows:Review of a community reported complaint received by the Rhode Island Department of Health on 10/24/2025 alleges that Resident ID #5 sustained 2 falls and did not get the appropriate care related to his/her injuries.Record review revealed that the resident was admitted to the facility in August of 2022 with diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral infarction (weakness and paralysis of one side of the body following a stroke), dependence on ventilator, use of tracheostomy (a surgically created opening in the windpipe to assist with breathing) and gastrostomy (a surgical opening into the stomach for purposes of feeding).Review of a care plan last updated on 7/29/2025 revealed an intervention that states, [Resident ID #5] requires assist of 2 for bathing, dressing, grooming, incontinent care.Review of an Annual Minimum Data Set assessment dated [DATE] revealed that the resident is totally dependent on staff for all activities of daily living including, turning from side to side, toileting, and transfers.Review of a progress noted dated 8/3/2025 revealed that the resident sustained a witnessed fall while a Nursing Assistant (NA) was changing his/her brief and landed on his/her bilateral knees. Additionally, the note revealed that the resident complained of 10 out of 10 pain and was to have x-rays of the affected area.Review of a, Radiology Results Report dated 8/4/2025 states in part, .Findings.there is a fracture of the distal tibia and fibulal fracture.Review of a facility provided statement authored by NA, Staff L, revealed that she was providing incontinence care to Resident ID #5 alone when s/he rolled out of bed and onto the floor.An interview was attempted with Staff L with no return call. During a surveyor interview on 10/28/2025 at approximately 12:00 PM with the Director of Nursing Services in the presence of the Administrator he was unable to provide evidence that the staff followed the care plan relative to utilizing 2 staff members for incontinence care.As the facility failed to follow the care plan with regards to utilizing two staff members for incontinence care, this resident was rolled off of the side of the bed and sustained a left distal tibia and fibula fracture. This failure by the facility to ensure that staff consistently implemented resident-specific interventions outlined in the care plan, thereby not providing care in accordance with accepted standards and the resident's assessed needs.

Based on record review and staff interview, it has been determined that the facility failed to have sufficient nursing staff to assure resident safety and attain the highest practicable, physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care relative to insufficient staffing for 1 of 3 residents reviewed for a fall, Resident ID #5. Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 10/24/2025 alleged that Resident ID #5 who is a .quadriplegic [paralysis of both arms and legs], dependent on a ventilator and feeding tube, and fully reliant on staff for all aspects of [his/her] care. the complaint alleged that on 9/29/2025, Resident ID #1 was found on the floor with a broken nose. Furthermore, the complaint alleged that the facility is .severely understaffed.Record review revealed that the resident was admitted to the facility in August of 2022 with diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral infarction (weakness and paralysis of one side of the body following a stroke), dependence on ventilator, use of tracheostomy (a surgically created opening in the windpipe to assist with breathing) and gastrostomy (a surgical opening into the stomach for purposes of feeding).Record review revealed that the resident sustained a fall on 9/29/2025 at 8:15 PM when the resident fell out of bed and was found on the floor which resulted in a nasal fracture.Review of the facility provided investigation file revealed that the facility was unaware of how the resident fell out of bed.Review of the statements authored by Nursing Assistant (NA), Staff P, dated 9/29/2025 revealed that on 9/29/2025, around 6:00 PM the NA and nurse went to assist a resident that required total dependence with care and required the 3 NA's working on the unit, a nurse from the unit and an additional NA from another floor to transfer the resident to bed safely. Additional review of the statement revealed that she asked the Administrator for help, but that he had to leave to pick up his kids. Further review of the statement revealed that with only three NAs on the floor, they .answered lights and did the best that they could. Around 7 PM this NA observed staff rushing into Resident ID #5's room, yelling that the resident is on the floor.During a surveyor interview with NA, Staff Q, on 10/28/2025 at 11:09 AM, she revealed that upon the beginning of her shift on 9/29/2025, they had 2 NA's until 4 PM and then another NA came. She revealed that the unit requires more staff than 2 NAs for the whole floor. She indicated that she reported to the management team that they needed more assistance on the unit but that none came. Furthermore, she revealed that while her and 4 other staff members were in another resident's room for a long time transferring the other resident, no other staff were present on the unit to be available if the other residents required assistance.During a surveyor interview with NA, Staff R, on 10/28/2025 at 11:26 AM, she revealed that on 9/29/2025 the unit was unsafe at the time of the event. She revealed that there was only 3 NAs working. Additionally, she revealed that if there was more staff that the resident probably wouldn't have fallen.Review of the facility assessment dated [DATE]-2026, revealed that staffing assignments are based on patient volume/density and acuity. Further review of the facility assessment failed to identify the average number of staff required to ensure sufficient number of qualified staff are available to meet each resident's needs, in the assessment or attached to the assessment in the supporting document section.Review of a document titled Staffing Guidelines that was provided after the surveyor notified the Administrator that their facility assessment does not identify the average number of staff required to ensure a sufficient number of qualified staff are available to meet each resident's needs, revealed that on the 3:00 PM to 11:00 PM shift, the unit that Resident ID #5 resides on, requires 5/4 NA's.Review of the facility's actual working schedule for the 3:00 PM to 11:00 PM shift on 9/29/2025 revealed, only two nurses and three NAs worked on the unit, and not the 5/4 NA's as stated in the Staffing Guidelines.During a surveyor interview on 10/28/2025 at approximately 1:55 PM, with the Administrator and Director of Nursing Services, they indicated that they were aware there were only 3 NAs scheduled to work on the unit. Additionally, they could not provide evidence that they followed their staffing guidelines and/or adjusted the staffing assignments based on patient volume/density and acuity of the unit. Furthermore, they acknowledged that Residents ID #5 had an unwitnessed fall from bed on 9/29/2025 where s/he fractured his/her nasal bone and at the time of the fall the unit was staffed with 3 NA's instead of the 5/4 NA's, as stated in the staffing guidelines.The facility failed to ensure that sufficient staffing levels were maintained in accordance with the facility's own staffing guidelines and resident acuity needs. As a result, Resident ID #5, who is fully dependent on staff for care, experienced an unwitnessed fall resulting in a nasal fracture. This demonstrates a failure by the facility to provide adequate supervision and to ensure the health and safety of residents through the consistent implementation of appropriate staffing levels and care practices.

Based on surveyor observation, record review, and resident representative and staff interviews, it has been determined that the facility failed to provide treatment and care in accordance with professional standards of practice, as because the facility failed to monitor a resident for side effects after s/he was administered significant antipsychotic medications in error, nursing failed to inform additional staff on the unit that an error had occurred in order to enable all staff to assist in the monitoring of the resident, the failure to notify a provider of the medication error timely, the failure to inform the resident's family of the error at all, and allowed a resident who required monitoring to leave the facility on a leave of absence (LOA), for 1 of 1 resident reviewed who required emergency medical transport, hospitalization, and ventilation (ventilators are lifesaving machines that can support breathing function in the body when diagnosed with critical health conditions), Resident ID #1. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health (RIDOH) on 6/19/2025 revealed that Resident ID #1 went home on a leave of absence (LOA) on 6/15/2025 and the facility was notified that the resident was sent emergently to an acute care hospital by the family. Furthermore, the report indicates that it was discovered that the resident had received 200 mg [milligrams] of Clozapine [Clozaril- a medication prescribed to treat major psychiatric diagnoses like schizophrenia] in error. Additional review of this facility reported incident revealed a note from the RIDOH triage nurse, that a phone call was placed to the facility upon receipt of this incident for clarification purposes where the administrator revealed that the resident had received this medication by a nurse in the facility and not from any family member during his/her LOA on 6/15/2025. Record review of a facility policy revised on 7/1/2024 titled, Medication Errors states in part, .Appropriate interventions will be implemented. Patients [residents] involved in a medication error will be evaluated for adverse effects and their provider and responsible party will be notified . Record review revealed Resident ID #1 was admitted to the facility in April of 2025 with diagnoses including, but not limited to, type 2 diabetes mellitus, dementia, bradycardia (low heart rate), nonrheumatic aortic valve stenosis (heart condition that makes it harder for blood to flow out of the heart to the rest of the body). Record review of a Quarterly Minimum Data Set assessment dated [DATE], revealed the resident is .rarely/never understood . Additionally, the assessment revealed that the resident has short and long-term memory problems. Further review revealed his/her cognitive skills for daily decision making is severely impaired. 1. Record review of an undated written statement authored by Registered Nurse, Staff A, revealed that on the morning of 6/15/2025 she administered another resident's (Resident ID #2) medications to Resident ID #1 at approximately 8:30 AM. Additionally, the statement stated that .I believe it was 200 mg of Clozapine, Calcium carbonate and a multivitamin. I was unable to identify the resident appropriately and when I had my initial encounter the resident must have misunderstood when I said [Resident ID #2's name] and thought I said [his/her name]. [Resident ID #1] ingested the medications and at that time an employee familiar with the residents identified the error .the resident remained in the dining area to ensure appropriate monitoring, vital signs were checked, and a note was documented in the system . During a surveyor interview with Licensed Practical Nurse (LPN) Staff B, on 6/23/2025 at 11:42 AM, she indicated that she was one of the two nurses assigned to work the unit on 6/15/2025 along with Staff A. Staff B, was the nurse that was assigned to care for Resident ID #1. Staff A was assigned to care for Resident ID #2. She observed Staff A standing over Resident ID #1 as if she was administering medications to the resident. Staff B then questioned Staff A about what was administered to the resident and Staff A responded that all the medications that were highlighted red on the screen (medications that are highlighted as red, indicate they are late for their scheduled administration time) were administered. Record review of Resident ID #2s June 2025 Medication Administration Record (MAR) revealed that Staff A documented the following medications as being administered at 9:47 AM on 6/15/2025: - Clozaril - 200 mg - Geodon (antipsychotic medication) 80 mg This indicates that Resident ID #1 was administered two significant antipsychotic medications in error. A surveyor telephone interview with Staff A was attempted on 6/23/2025 at 10:33 AM and 6/25/2025 at 10:57 AM, however, she did not answer and has not returned the surveyor's calls. 2. During a surveyor observation and interview on 6/23/2025 at approximately 11:00 AM, with the resident's spouse and one of their children, in the presence of Resident ID #1, revealed Resident ID #1 was wearing a name band on his/her left wrist. The resident's child stated the name band is always in place and was present on 6/15/2025 when s/he visited the resident in the hospital. The spouse indicated s/he arrived at the facility at approximately 10:00 AM on 6/15/2025. When the spouse arrived at the facility the resident was asleep in his/her wheelchair in the dayroom. Additionally, the spouse revealed that s/he brought the resident to his/her room to watch church on television then signed him/her out at 11:00 AM to go to their child's home, who lives close to the facility. Furthermore, s/he revealed that when they arrived at their child's home the resident immediately became unresponsive and 911 was called. Lastly, the resident's spouse revealed that although s/he had been in the facility visiting with the resident for approximately an hour prior to taking him/her out on a LOA, none of the facility's staff had informed him/her that the resident had received the incorrect medications that morning and indicated if s/he was told then s/he would have never taken the resident out of the facility. This interview indicates that the resident's spouse was not informed of the resident's medication error prior, while s/he remained in the facility with the resident for approximately one hour while s/he was in the facility visiting, prior to him/her taking the resident out for a LOA. During the surveyor interview with Staff B, on 6/23/2025 at 11:42 AM, she indicated that she did see the resident's spouse in the facility visiting the resident after the medication errors had been made. Additionally, she revealed that she did not inform him/her of the medication errors because she was waiting to speak with a provider first. Furthermore, she revealed that she did not call the resident's provider to inform them of the medication error that had occurred until after the resident's family presented to the facility to obtain documentation from the facility for the Emergency Medical Services (EMS) transport. 3. During the surveyor interview with Staff B, on 6/23/2025 at 11:42 AM, she indicated that she left the unit at some point to respond to an emergency after Resident ID #1 was administered medications in error. She further revealed that she did not obtain the resident's vitals, indicated that Staff A told her she did. Record review of a Summary for Providers progress note created on 6/15/2025 at 1:49 PM, authored by Weekend Supervisor, LPN Staff C, revealed vital signs that were documented in the progress note were taken in May of 2025 and not taken in real time. During a surveyor telephone interview on 6/25/2025 at 2:30 PM, with Staff C, she revealed that she was the weekend supervisor on 6/15/2025 during the hours of 7:00 AM - 7:00 PM. Additionally, she indicated that she was notified that Staff A had administered medications in error to Resident ID #1 during the morning medication pass, after the resident was already out of the facility on a LOA with his/her family and enroute to the hospital. She further indicated that she documented the above-mentioned Summary for Providers note and acknowledged that the vital signs were from May of 2025. Staff C further stated the vital signs auto populate from the electronic medical record and indicated that she did not assess Resident ID #1 because s/he was already out of the facility at the time the progress note was created by her. 4. Additional record review revealed the on-call Nurse Practitioner's (NP) progress note dated 6/15/2025 at 8:02 PM, which states in part, .Per nursing, patient inadvertently received 200mg clozaril and 1 Tums [calcium carbonate] at 10am that was meant for another patient. According to nursing, the [spouse] then 'took [the patient] out of facility and brought [him/her] home.' Nursing was notified by patient's [spouse] that [s/he] had called EMS [Emergency Medical Services] while at home due patient's 'increased lethargy' and [s/he] was transferred to the hospital for further evaluation. Nursing states that the [spouse] took patient from the facility without notifying any staff or signing patient out .Call back on-call if/when patient returns to facility . This indicates that the on-call NP was not informed that the resident received the medications in error until approximately 9 hours after the incident occurred and the resident had already been emergently transported to the hospital via EMS. Additionally this note indicates that she was not informed that the resident also received Geodon 80 mg in error. 5. During the surveyor interview with Staff B, on 6/23/2025 at 11:42 AM, she revealed that the facility was unaware that the resident left the facility until the family returned to the facility to request paperwork for the EMS transport. During a surveyor interview on 6/23/2025 at 11:15 AM, with RN Staff D she indicated that the LOA Book, which contains sign out sheets for residents leaving the facility for LOA, is kept at the nurse's station. During a surveyor interview on 6/24/2025 at 1:26 PM, with Nursing Assistant (NA) Staff E, she indicated that she was one of the NAs assigned to work on Resident ID #1's unit on 6/15/2025 during the 7:00 AM - 3:00 PM shift. Additionally, she revealed that she was not informed by the nurses that the resident had received medications in error or that s/he should remain in the facility for monitoring. This indicates that neither Staff A or Staff B, attempted to assess the resident because if they had, they would have been aware of his/her absence prior to the resident's family presenting to the facility for paperwork to provide to EMS, or that either of them informed the other employees working on the unit of the medication errors so that they could have assisted in the monitoring of Resident ID #1 for any adverse effects s/he may have experienced as result of the medications s/he had received in error. Additionally, during the surveyor interview on 6/24/2025 at 1:26 PM, with Staff E, she indicated that she was one of the NAs assigned to work the unit on 6/15/2025 during the 7:00 AM - 3:00 PM shift. Additionally, she indicated that she had provided the resident's spouse with the LOA Book to sign Resident ID #1 out of the facility. Record review of the document titled, LEAVE OF ABSENCE FORM, in the LOA Book revealed that the resident was signed out by his/her spouse on 6/15/2025 at 11:00 AM. This indicates that from the time the resident received the medications in error, until s/he left the faciity on an LOA at approximately 11:00 AM (for more than 2 hours), Staff B, the nurse assigned to care for Resident ID #1, failed to monitor Resident ID #1 for any adverse effects from the medications that were not prescribed to him/her. Furthermore, Per Staff E's interview, the staff working on the unit were not made aware of the error, so they were unaware that the resident required enhanced monitoring for adverse effects of the medications. Additionally, this would also indicate that although the resident's spouse followed protocol and requested the LOA book from a staff member and signed out the resident as required, Staff B did not review the LOA book, indicating she was not actively trying to locate the whereabouts of her resident that experienced a significant medication error for monitoring. During a surveyor interview with the Medical Director on 6/23/2025 at 2:03 PM, he indicated that the resident should not have been allowed to leave the facility on LOA but should have remained in the facility for monitoring. Further record review failed to reveal evidence that any interventions were implemented after the resident was administered the medications intended for a different resident. Additionally, the record failed to reveal evidence that Resident ID #1 was monitored in real time for adverse effects in the hours immediately following the time the medication errors were made as s/he was permitted to leave the facility on an LOA with his/her spouse who was unaware that an error had occurred. Lastly, the record failed to reveal evidence that the provider was informed of the medication errors prior to the resident leaving the facility with his/her spouse, becoming unresponsive and being transferred to the hospital. During a surveyor interview with the Director of Nursing Services in the presence of the Administrator on 6/23/2025 at 1:35 PM, he acknowledged that Staff A failed to properly identify Resident ID #1 although s/he was wearing a name band. Additionally, he revealed that he would have expected Staff A to properly identify Resident ID #1 by his/her name band and administer the correct medications to the correct resident. Lastly, he revealed that he was unaware that the resident was administered Geodon in addition to the other medications, until it was brought to his attention by the surveyor. Lastly, he acknowledged that Staff A did document that she administered the Geodon to the resident at the same time as the other medications. Although Staff A's statement indicated that the resident remained in the dining area to ensure appropriate monitoring, the vital signs and note she documented in the resident's record were not entered until the day following the incident. Additionally, per the surveyor interview with the resident's spouse, the resident was found sleeping and unattended in the day room. The spouse remained in the facility for approximately one hour and s/he did not observe staff assessing the resident. The resident was signed out and then left the faciity on an LOA with his/her spouse, who had not been informed of the medication error that had been made hours prior, even though, per Staff B's interview, the facility was aware s/he was there. Moreover, per Staff E's interview, she had not been informed that an error had occurred and was unaware that the resident required any enhanced monitoring for adverse effects and provided the resident's spouse with the LOA book. Furthermore, Staff B revealed during her interview that she was unaware that the resident had left the faciity on an LOA. Lastly, record review revealed that the vital signs that were documented regarding this incident by RN, Staff A, were not entered into the record until 6/16/2025, the day after the incident occurred and while the resident was in the hospital and the vital signs that were entered on the Summary for Providers progress note were from May of 2025. As a result of this survey, it has been determined that Resident ID #1 was at risk for serious harm, injury, impairment or death due to Staff A's failure to administer medications according to the facility's policy, when she prepared and administered the medications. Resident ID #1 was administered medications intended for Resident ID #2 which resulted in Resident ID #1 exhibiting adverse effects caused by Clozaril and Geodon, which resulted in Resident ID #1 to be transferred and admitted to a hospital, where s/he required ventilation and treatment for toxic metabolic encephalopathy (a condition that disrupts normal brain function). Cross reference F580 and F760

Based on surveyor observation, record review, and resident representative and staff interview, it has been determined that the facility failed to ensure that residents are free from significant medication errors for 1 of 1 resident reviewed who was administered psychiatric medications that were prescribed for another resident, who required emergency medical transport, hospitalization, and ventilation. Medical ventilators are lifesaving machines that can support breathing function in the body when diagnosed with critical health conditions. These intervention were necessary as a result of medication errors involving Resident ID #1. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health (RIDOH) on 6/19/2025 revealed that Resident ID #1 went home on a leave of absence (LOA) on 6/15/2025 and the facility was notified that the resident was sent emergently to an acute care hospital by the family. Furthermore, the report indicates that it was discovered that the resident had received 200 mg [milligrams] of Clozapine [Clozaril- a medication prescribed to treat major psychiatric diagnoses like schizophrenia] in error. Additional review of this facility reported incident revealed a note from the RIDOH triage nurse, that a phone call was placed to the facility upon receipt of this incident for clarification purposes where the administrator clarified that the resident had received this medication by a nurse in the facility and not from any family member during his/her LOA on 6/15/2025. Record review of the facility policy revised on 1/1/2022 titled, General Dose Preparation and Medication Administration, states the following in part, .Prior to administration of medication, Facility staff should take all measures required by Facility policy and including, but not limited to the following .Verify each time a medication is administered that it is the correct medication, at the correct dose .for the correct resident .Identify the resident per Facility policy . Record review of the Food and Drug Administration's prescribing information for Clozaril states in part, .ORTHOSTATIC HYPOTENSION [a sudden drop in blood pressure when a person stands or changes position], WITH OR WITHOUT SYNCOPE [fainting], CAN OCCUR WITH CLOZAPINE TREATMENT .COLLAPSE CAN BE PROFOUND AND BE ACCOMPANIED BY RESPIRATORY AND/OR CARDIAC ARREST. ORTHOSTATIC HYPOTENSION IS MORE LIKELY TO OCCUR DURING INITIAL TITRATION IN ASSOCIATION WITH RAPID DOSE ESCALATION. IN PATIENTS WHO HAVE HAD EVEN A BRIEF INTERVAL OFF CLOZAPINE, i.e., 2 OR MORE DAYS SINCE THE LAST DOSE, TREATMENT SHOULD BE STARTED WITH 12.5 mg ONCE OR TWICE DAILY .ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS TREATED WITH ANTIPSYCHOTIC DRUGS ARE AT AN INCREASED RISK OF DEATH . Record review of the manufacturer's prescribing information for Geodon states the following in part, .GEODON is not approved for the treatment of patients with dementia-related psychosis. Elderly patients with a diagnosis of psychosis related to dementia treated with antipsychotics are at an increased risk for death .one potential side effect is that it may change the way the electrical current in your heart works .Your risk of dangerous changes in heart rhythm can be increased if you are taking certain other medicines and if you already have certain abnormal heart conditions . Record review revealed Resident ID #1 was admitted to the facility in April of 2025 with diagnoses including, but not limited to, type 2 diabetes mellitus, dementia, bradycardia (low heart rate), nonrheumatic aortic valve stenosis (heart condition that makes it harder for blood to flow out of the heart to the rest of the body). Record review of a Minimum Data Set assessment dated [DATE], revealed the resident is rarely/never understood. Additionally, the assessment revealed that the resident has short and long-term memory problems. Further review reveals his/her cognitive skills for daily decision making is severely impaired. Record review of an undated written statement authored by Registered Nurse, Staff A, revealed that on the morning of 6/15/2025 she administered another resident's (Resident ID #2) medications to Resident ID #1 at approximately 8:30 AM. Additionally, the statement stated that I believe it was 200 mg of Clozapine, Calcium carbonate and a multivitamin. I was unable to identify the resident appropriately and when I had my initial encounter the resent must have misunderstood when I said [Resident ID #2's name] and thought I said [his/her name]. [Resident ID #1] ingested the medications and at that time an employee familiar with the residents identified the error . A surveyor telephone interview with Staff A was attempted on 6/23/2025 at 10:33 AM and 6/25/2025 at 10:57 AM, however, she did not answer and has not returned the surveyor's calls. During a surveyor interview with Licensed Practical Nurse (LPN), Staff B, on 6/23/2025 at 11:42 AM, she indicated that on the morning of 6/15/2025 she was the nurse assigned to care for Resident ID #1. Additionally, Staff B indicated that she observed Staff A standing over Resident ID #1 with a medication cup in her hand as if she had just administered medications to the resident. She then questioned herself as to why, because Resident ID #1 was assigned to her and she had already administered the resident's morning medications to him/her. Additionally, she revealed that she approached Staff A and questioned if and/or what medications she had administered to Resident ID #1 and Staff A responded that all of the medications that were highlighted red on the screen (medications that are highlighted as red, indicate they are late for their scheduled administration time) were administered. Record review of Resident ID #2's June 2025 Medication Administration Record (MAR) revealed that Staff A documented the following medications in part as being administered at on 6/15/2025 9:47 AM: - Clozaril 200 mg - Geodon (an antipsychotic medication) 80 mg This indicates that Geodon, another significant antipsychotic medication, which has significant side effects, was also administered to Resident ID #1 in error. Record review of Resident ID #1's June 2025 MAR revealed s/he received the following medications on the morning of 6/15/2025: - Citalopram (an antidepressant) 40 mg - Norvasc (a medication prescribed to treat high blood pressure) 2.5 mg - Lisinopril (a medication prescribed to treat high blood pressure) 20 mg - Gabapentin (a medication prescribed to treat nerve pain; it works by reducing the excitability of nerve cells in the brain) Additional record review for Resident ID #1 failed to reveal evidence of a physician's order for Clozaril 200 mg or Geodon 80 mg. During a surveyor observation and interview on 6/23/2025 at approximately 11:00 AM, with the resident's spouse and one of their children, in the presence of Resident ID #1, revealed Resident ID #1 was wearing a name band on his/her left wrist. The resident's child stated the name band has been on him/her and was present on the resident on 6/15/2025 when s/he visited him/her in the hospital. The spouse indicated s/he arrived at the facility at approximately 10:00 AM on 6/15/2025. When the spouse arrived at the facility s/he found the resident asleep in his/her wheelchair in the dayroom. Additionally, the spouse revealed that s/he brought the resident to his/her room and watched church services on the television, s/he then signed the resident out for an LOA at 11:00 AM to go to their child's home, who lives nearby the facility. Furthermore, s/he revealed that when they arrived at their child's home the resident immediately became unresponsive and s/he called 911. Lastly, the resident's spouse revealed that although s/he had been in the facility visiting with the resident for approximately an hour prior to taking him/her out on an LOA, none of the facility's staff had informed him/her that the resident had received the incorrect medications that morning. S/he indicated that if s/he knew the resident received someone else's medications, s/he would have never have taken the resident out of the facility. Record review of the Emergency Medical Services (EMS) Patient Care Report document dated 6/15/2025 at 11:17 AM, revealed that upon arrival the resident was found sitting in a wheelchair, slumped over, breathing, but responsive to painful stimulation only. The report further indicates that the resident's family reported that s/he was sleepy and not him/herself earlier that day while at the nursing home. S/he was placed in the ambulance and noted his/her assessment and vital signs as a shallow respiratory rate (type of breathing that that can make it harder to get enough oxygen into your lungs) at 14 breaths per minute (BPM, normal range for a healthy adult is 12 - 20). The note also revealed that the resident was placed on oxygen at 15 liters per minute via a non-rebreather mask (a medical device usually used in emergencies where someone needs a lot of oxygen quickly). Furthermore, the document revealed that the resident was transported to the hospital and reassessed every five minutes. While enroute his/her respiratory rate fell below 8 BPM, and his/her blood pressure decreased requiring intravenous fluids and ventilation (a machine or device used medically to support or replace the breathing of a person who is ill or injured). In addition, the resident's family member accompanied him/her in the ambulance and received notification from the nursing home via telephone that the resident was administered the wrong medication earlier in the day. Lastly, the document revealed the following vital signs: - 6/15/2025 11:30 AM, blood pressure 104/59 (normal is 120/80) and respirations shallow at 6 BPM - 6/15/2025 11:47 AM, blood pressure 82/26 and respirations 12 while mechanically assisted Record review of the hospital documentation revealed that the resident was reportedly in his/her usual state of health until at approximately 9:00 AM or 10:00 AM on 6/15/2025 s/he was erroneously given a dose of clozapine 200 mg at his/her nursing home which was intended for another resident. .Patient [resident] subsequently became acutely encephalopathic (abnormal brain function). Poison control contacted .Patient was admitted after accidentally [s/he] received an overdose 200 mg of clozapine. Additionally, the documents revealed that s/he was admitted and treated for accidental overdose of clozapine, toxic metabolic encephalopathy (a temporary brain problem caused by a harmful substance like drugs or medications). Further review failed to reveal evidence that the facility informed the hospital that the resident also received Geodon 80 mg, that was intended for a different resident. During a surveyor interview with the Medical Director on 6/23/2025 at 2:03 PM, he indicated that the resident should not have been allowed to leave the facility on LOA and should have remained in the facility to be monitored. During a surveyor interview with the Director of Nursing Services in the presence of the Administrator on 6/23/2025 at 1:35 PM, he acknowledged that Staff A failed to properly identify Resident ID #1 although s/he was wearing a name band, which resulted in the significant mediation errors. Additionally, he acknowledged that he would have expected Staff A to properly identify Resident ID #1 and administer the correct medications to the correct resident. Lastly, he revealed that he was unaware that the resident was administered Geodon erroneously as well and acknowledged that Staff A documented the Geodon as administered at the same time as the clozapine was administered, until it was brought to his attention by the surveyor. As a result of this survey, it has been determined that Resident ID #1 was at risk for serious harm, injury, impairment or death due to Staff A's failure to administer medications according to the facility's policy, when she prepared and administered the medications. Resident ID #1 was administered medications intended for Resident ID #2 which resulted in Resident ID #1 exhibited adverse effects caused by Clozaril and Geodon, which resulted in Resident ID #1 to be transferred and admitted to a hospital, where s/he required ventilation and treatment for toxic metabolic encephalopathy. Cross reference F580 and F684

Based on record review, resident representative and staff interviews, it has been determined that the facility failed to immediately consult with the resident's physician and inform the resident's representative when there was a need to commence a new form of treatment to deal with a problem for 1 of 1 resident reviewed who was administered medications in error, Resident ID #1. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health (RIDOH) on 6/19/2025 revealed that Resident ID #1 went home on a leave of absence (LOA) on 6/15/2025 and the facility was notified that the resident was sent emergently to an acute care hospital by the family. Furthermore, the report indicates that it was discovered that the resident had received 200 mg [milligrams] of Clozapine [Clozaril- a medication prescribed to treat major psychiatric diagnoses like schizophrenia] in error. Additional review of this facility reported incident revealed a note from the RIDOH triage nurse, that a phone call was placed to the facility upon receipt of this incident for clarification purposes where the administrator revealed that the resident had received this medication by a nurse in the facility and not from any family member during his/her LOA on 6/15/2025. Record review revealed the resident was admitted to the facility in April of 2025 with diagnoses including, but not limited to, type 2 diabetes mellitus, dementia, bradycardia (low heart rate), nonrheumatic aortic valve stenosis (heart condition that makes it harder for blood to flow out of the heart to the rest of the body). Record review of a Quarterly Minimum Data Set assessment dated [DATE], revealed the resident is .rarely/never understood . Additionally, the assessment revealed that the resident has short and long-term memory problems. Further review revealed his/her cognitive skills for daily decision making is severely impaired. Record review of an undated written statement authored by Registered Nurse (RN), Staff A, revealed that on the morning of 6/15/2025 she administered another resident's (Resident ID #2) antipsychotic medications to Resident ID #1 at approximately 8:30 AM. Additionally, the statement revealed that a staff member familiar with the residents identified the medication errors. During a surveyor interview with Licensed Practical Nurse, Staff B, on 6/23/2025 at 11:42 AM, she revealed that she and Staff A were the two nurses assigned to work on Resident ID #1's unit on 6/15/2025. Additionally, Staff B revealed that she was the nurse that was assigned to care for Resident ID #1 on that date. She revealed that she observed Staff A standing over Resident ID #1 as if she was administering medications to him/her. Staff B then questioned Staff A about what was administered to the resident and Staff A replied she administered all the medications that were highlighted red on the screen (medications that are highlighted as red, indicate they are late for their scheduled administration time) were administered. Furthermore, she revealed that Staff A had administered another resident's medications, Resident ID #2, to Resident ID #1. Record review of Resident ID #2s June 2025 Medication Administration Record revealed that Staff A documented the following medications as being administered at 9:47 AM on 6/15/2025: - Clozaril - 200 mg - Geodon (antipsychotic medication) 80 mg This indicates that Resident ID #1 was administered two significant antipsychotic medications in error. A surveyor telephone interview with Staff A was attempted on 6/23/2025 at 10:33 AM and 6/25/2025 at 10:57 AM, however, she did not answer and has not returned the surveyor's calls. Additionally, during the surveyor interview with Staff B, on 6/23/2025 at 11:42 AM she revealed that she saw Resident ID #1's spouse in the facility visiting with him/her after the medication errors had been made. Additionally, she revealed that she did not inform the spouse of the medication errors because she was waiting to speak with a provider first. During a surveyor interview on 6/23/2025 at approximately 11:00 AM, with the resident's spouse and one of their children, in the presence of Resident ID #1, The spouse indicated that s/he arrived at the facility at approximately 10:00 AM on 6/15/2025 and took the resident out of the facility on a LOA at 11:00 AM to go to their child's home, who lives nearby the facility. Furthermore, s/he revealed that when they arrived at their child's home the resident immediately became unresponsive, and s/he called 911. Lastly, the resident's spouse revealed that although s/he had been in the facility visiting with the resident for approximately an hour prior to taking him/her out on an LOA, none of the facility's staff had informed him/her that the resident had received the incorrect medications that morning. S/he indicated that if s/he knew the resident received someone else's medications, s/he would have never have taken the resident out of the facility. Lastly, they revealed they were not made aware of the medication error until they presented back to the facility to acquire a copy of the resident's advance directive to provide to Emergency Medical Services (EMS). Furthermore, during the surveyor interview with Staff B, on 6/23/2025 at 11:42 AM she revealed that she did not call the resident's provider to inform them of the medication error that had occurred until after the resident's family presented to the facility to obtain documentation from the facility for EMS transport to the hospital. The surveyor interview with Staff B, on 6/23/2025 at 11:42 indicates that the facility failed to immediately consult with the resident's physician and inform the resident's representative when there was a need to commence a new form of treatment to deal with the medication error. During a surveyor interview with the Director of Nursing Services in the presence of the Administrator on 6/23/2025 at 1:35 PM, they were unable to provide evidence that the facility immediately consulted with the resident's physician and informed the resident's representative when there was a need to commence a new form of treatment to deal with a problem for Resident ID #1. Additional record review revealed the resident required emergency medical transport, hospitalization, and ventilation assistance (ventilators are lifesaving machines that can support breathing function in the body when diagnosed with critical health conditions) because s/he received medications that were not prescribed for him/her. Cross reference F684 and F760

Based on record review staff and resident interview, it has been determined that the facility failed to ensure that the resident receives adequate supervision to prevent an elopement for 3 of 6 residents reviewed who were identified as an elopement risk, Resident ID #s 1, 2, and 4. Review of a community reported complaint received by the Rhode Island Department of Health on 8/14/2024 alleged that Resident ID #1 eloped from the facility over the weekend and was found at a local convenience store. Review of a facility policy titled, SLA111 Elopement of Resident last revised in May of 2024, states in part, .definitions elopement occurs when a resident who is cognitively, physically, mentally, emotionally .impaired and is no longer making decisions on their own behalf wanders away, walks away, runs away, escapes, or otherwise leaves the community or environment unsupervised, unnoticed sign in/out records will be maintained and utilized whenever a resident leaves the community grounds alone .Elopement drills will be conducted a minimum of twice per year and documented on elopement drill documentation form .if the behavior is due to an acute illness assist the family in providing private care or institute frequent checks to ensure resident safety .For resident who have a permanent decline in status notify the physician/provider and family in writing that the resident will be transferred to a secure dementia unit .until placement can be arranged, community staff and family will provide sufficient supervision to ensure resident safety. For residents identified as being at risk for elopement, an elopement prevention plan will be developed with resident and family participation .A communication will be provided to all care givers regarding the resident's risk for elopement and prevention measures . Review of a facility policy titled, OPS100 Accident/Incidents last revised 3/1/2024, states in part, POLICY center staff will report, review, and investigate all accidents/incidents which occurred .involving, a patient who is receiving services .The licensed nurse will Report accidents/incidents and assist with completion of timely investigation to determine root cause .implement appropriate interventions based on conclusions. Update the care plan and communicate with the patient and appropriate representative . 1. Record review revealed that Resident ID #1 was admitted to the facility in June of 2023 with diagnoses including, but not limited to, dementia, Bipolar (mood disorder), Neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to decline in thinking reasoning and independent functioning) and visual hallucinations. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating s/he has a moderate cognitive impairment. Record review of an Elopement Evaluation dated 6/7/2024 indicated that Resident ID #1 was able to self-propel in his/her wheelchair independently, has expressed a desire to leave and has a history of actual elopement or attempted elopement. Further review of this Elopement Evaluation failed to indicate whether the resident was identified as an elopement risk, or not considered an elopement risk, or if interventions should be implemented to ensure the resident's safety. Review of a care plan dated 7/26/2023 revealed Resident ID #1 exhibits verbal behaviors and behaviors not directed at others, has a history of picking at his/her skin and putting himself/herself on the floor. Interventions included, but were not limited to, evaluate the need and provide for psych and behavioral health consultation. Further review revealed a care plan dated 6/8/2023 indicating Resident ID #1 is at risk for complications related to psychotropic medication use with interventions including, but not limited to, completed behavior monitoring in the electronic medical record. Additional review of the resident's care plan revealed the document was revised on 9/7/2023 and indicated the resident is at risk for falls with interventions including to keep the resident within view of staff when out of bed to the wheelchair. Record review of the progress notes revealed the following: -7/17/2024 Resident history of dementia and intermittent behaviors s/he wishes to leave the facility and go to the restaurant however there is no safe conduit for him/her to do this. -7/23/2024 Resident states s/he was outside and decided to pick up cigarette remnants when leaning forward s/he fell forward out of his/her wheelchair. S/he complained of knee pain and was noted with abrasions to his/her hand and contusion (bruising) to his/her right knee. -8/7/2024 Chief complaint recurrent fall and alcohol abuse. Resident states that during his/her leave of absence s/he was drinking alcohol the resident's family member was upset with this. Being his/her healthcare proxy/power of attorney family states s/he is no longer allowed to leave unless accompanied by staff or going to a medical appointment. -8/8/2024 Chief complaint dementia resident is having increased behaviors requiring multiple redirections. Resident feels anxious. Resident continues to make a cognitive as well as physical decline related to his/her dementia and s/he often has memory lapses and does not recall information given to him/her. -8/10/24 a family member of another resident called the facility to make the facility aware the resident was noted to be at the local convenience store. Record review failed to reveal evidence of an intervention for Resident ID # 1 after s/he fell outside of the facility while unattended on 7/23/2024 attempting to pick up smoking remnants. Additionally, the facility failed to follow Resident ID#1's care plan relative to keeping him/her within view of staff while out of bed in his/her wheelchair. During a surveyor interview with the Director of Nursing Services on 8/15/2024 at 11:11 AM, he indicated that an Elopement Evaluation assessment dated [DATE] had identified that Resident ID #1 was at risk for elopement based on the results. Additionally, he acknowledged that the Elopement Evaluation utilized by the facility does not indicate whether the resident was identified as an elopement risk, or if interventions should be implemented to ensure the resident's safety. Additionally, he was unable to provide evidence of an intervention or update to the resident's plan of care after his/her fall on 7/23/2024 while outside of the facility unattended. Additional record review failed to reveal evidence that interventions were implemented to remediate the resident's risk after s/he was found to be at risk for elopement on 6/7/2024. Record review revealed that on 8/10/2024, at an undetermined time, the facility was notified by a visitor that there was a resident at the convenience store approximately 0.2 miles from the facility. During a surveyor interview on 8/15/2024 at 11:36 AM, with Receptionist, she revealed the last time she saw the resident on 8/10/2024 was at approximately 10:00 AM in the lobby in his/her wheelchair. She indicated she was not aware of the resident's elopement risk status. 2. Record review revealed that Resident ID #4 was admitted to the facility in June of 2023 with a diagnosis including, but not limited to, dementia. Review of the MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15, indicating s/he had a moderate cognitive impairment. Record review of an Elopement Evaluation dated 5/17/2024, which indicated that the Resident ID #4 was able to self-propel independently in his/her wheelchair, has a history of actual or attempted elopement, and has a history of wandering that places the resident at significant risk of getting to a potentially dangerous place. Further review of the Elopement Evaluation failed to indicate whether the resident was identified as an elopement risk, or not considered an elopement risk, or if interventions should be implemented to ensure the resident's safety. Record review of an Occupational therapy OT evaluation & plan of treatment, dated 7/2/2024, at 11:01 AM states in part, .At the time of evaluation, writer looked throughout the building and unable to locate [him/her]. Asked Registered Nurse (RN), Nursing Assistant and Unit Manger [sic] and no one knew where [s/he] was, as they assumed [s/he] was sitting outside in usual areas. At that time, receptionist came to let me know that another RN called the facility and stated [s/he] was at [a local convenience store] .this writer immediately went to the store .issues arose when approaching Rt. 3 there is no sidewalk access from [store parking lot] to woodland Drive, requiring client to drive into traffic on Rt. 3 to make a U-turn onto Woodland. Also, there are several patch jobs on the concrete that are showing significant wear and tear .[his/her] wheelchair did buckle/[NAME] with the changes in pitch. On woodland Drive, same issues no sidewalk. Did have changes in pitch with wear and tear of the pavement .it was determined [s/he] has no cell phone. This is a concern if the client has an issue of wheelchair getting stuck on uneven ground .also noted that there was no reflective tape or flag that increases [his/her] visibility for oncoming traffic .due path to [NAME] Farms .several areas of concern including uneven ground, with no way of calling for assistance if wheelchair became stuck or tips. Client needs to drive on the road due to no sidewalk access, including onto Rt. 3 with fast moving traffic. Recommendation .the client is supervised during traveling on Woodland Drive and Rt.3 to ensure [his/her] safety is maintained. Record review failed to reveal evidence of an update to Resident ID #4's plan of care related to the above-mentioned recommendation. Record review of an Elopement Evaluation assessment dated [DATE], which was conducted as a result of Resident ID #1's elopement on 8/10/2024 assessment indicated, that Resident ID #4 was able to self-propel independently in his/her wheelchair and has a history of wandering that places the resident at significant risk of getting to a potentially dangerous place. Further review of this Elopement Evaluation failed to indicate whether Resident ID #4 was identified as an elopement risk or if interventions should be implemented to ensure the resident's safety. Record review of a care plan dated 8/12/2024 revealed a focus care area indicating Resident ID #4 is at risk for elopement with a goal the resident will not attempt to leave the facility without an escort and interventions including, but not limited to, redirect resident if near exits or doorways. On 8/15/2024 at 11:36 AM during a surveyor interview being conducted over the telephone, the receptionist who was off duty, stated in part, [Resident ID #4] is down the street from the facility and should not be. She then tried to coax the resident into going back to the facility and Resident ID #4 would not. The surveyor immediately went to the Administrator's office and informed him that Resident ID #4 was observed by the receptionist down the street from the facility. During a surveyor interview and simultaneous observation on 8/16/2024 at 11:55 AM with Resident ID #4 s/he indicated that s/he goes outside when s/he wants. During a surveyor interview on 8/16/2024 at 11:59 AM with Registered Nurse, Staff A, she indicated that Resident ID #4 did not make her aware s/he was leaving the unit and going outside or off premises on 8/15/2024. Additionally, she indicated she was not aware of the resident's elopement risk identified on 5/17/2024 and 8/11/2024. Further, she was unaware that the resident had left the unit and was outside on 8/16/2024 at the time of the interview. During a surveyor observation on 8/16/2024 at 12:04 PM Resident ID #4 was observed outside the back door of the facility unattended in his/her motorized wheelchair. During a surveyor interview with the Director of Nursing Services immediately following the above-mentioned observation, he indicated Resident ID #4 requires supervision by staff when outside of the building. Additionally, he indicated he was unaware that the resident was outside unattended. 3. Record review revealed that Resident ID #2 was admitted to the facility in June of 2023 with diagnoses including, but not limited to, dementia with other behavioral disturbance and anxiety. Review of the MDS assessment dated [DATE] revealed a BIMS score of 7 out of 15, indicating s/he has a severe cognitive impairment. Record review of an Elopement Evaluation dated 8/11/2024 which was conducted as a result of Resident ID #1's elopement on 8/10/2024 assessment indicated, Resident ID #2 was able to self-propel independently in his/her wheelchair and has a history of wandering that places the resident at significant risk of getting to a potentially dangerous place. Further review of this Elopement Evaluation failed to indicate whether the resident was identified as an elopement risk or if interventions should be implemented to ensure the resident's safety. Review of a care plan dated 8/12/2024 revealed Resident ID #2 is at risk for wandering/elopement with an intervention including the resident will engage in unit therapeutic activities. During a surveyor interview on 8/15/2024 at 10:26 AM with Nursing Assistant, Staff B, she indicated she was assigned to Resident ID #2 and the resident is able to self-propel in his/her wheelchair. Additionally, she indicated she was unaware of the resident's risk for elopement or that there was an intervention in place. During a surveyor interview on 8/15/2024 at 11:01 AM with Licensed Practical Nurse, Staff C, she indicated she was not aware that Resident ID #2 was identified as an elopement risk. During a surveyor interview on 8/14/2024 at 3:02 PM and 8/16/2024 at 12:20 PM with the Director of Nursing Services, he acknowledged that the Elopement Evaluation assessments completed for resident ID #s 1, 2 and 4 indicated that they were an elopement risk and he was unable to provide evidence that the staff was educated on the possible risks identified. Additionally, he was unable to provide evidence that the facility implemented interventions to prevent the elopement of Resident ID #1 after his/her risk was identified on 6/7/2024. Further, he acknowledged Resident ID #s 1 and 4 were able to exit the facility and were located off facility premises going down the roadway toward a high traffic intersection. Lastly, he was unable to provide evidence that the facility implemented any interventions for Resident ID #4 after s/he was observed by staff off the premises on 8/15/2024. During a surveyor interview on 8/16/2024 at 3:35 PM with the Administrator, he was unable to provide evidence the facility preformed two elopement drills within 12 months, per facility policy. During a surveyor interview on 8/16/2024 at 3:54 PM with the Medical Director, he indicated it would his expectation that both Resident ID #1 and 4 would have been supervised by staff while outside of the building.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that each resident receives necessary respiratory care and services in accordance with professional standards of practice for 15 of 15 residents reviewed with a tracheostomy (a medical procedure that involves creating an opening in the neck to place a tube into a person's trachea, or windpipe), relative to oral care with suctioning, Resident ID #s 1, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17. Findings are as follows: Record review of a facility reported incident submitted to The Rhode Island Department of Health on 5/23/2024 revealed in part that a resident alleged that on 5/22/2024 the second shift nurse shoved mouthwash two times in his/her mouth with no suction. Record review failed to reveal evidence that the facility has a policy or procedure on how to perform oral care on residents with a tracheostomy. 1. Record review revealed Resident ID #1 was readmitted to the facility in March of 2024 with diagnoses including, but are not limited to, stroke, tracheostomy status and locked in state (a complex condition presenting with quadriplegia due to damage in the brain stem where cognition, blinking and hearing are classically preserved). Record review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status was completed with a score of 14 out of 15 indicating intact cognition. Further review revealed s/he requires respiratory treatments including, but not limited to, suctioning, tracheostomy care and invasive mechanical ventilator (a type of therapy that helps you breathe or breathes for you when you can't breathe on your own). Record review of a care plan dated 4/5/2019 and revised 4/19/2022 reveals a focus care area for risk for oral health or dental care problems as evidenced by poor dentition with interventions including, but not limited to, provide oral hygiene/mouth care twice per day and as needed. Further review of the care plan revealed a focus care area revised on 7/6/2021 that the resident is at risk for respiratory complications related to tracheostomy and chronic ventilator with interventions including, but not limited to, suction tracheotomy and airway as needed. Record review revealed the following physician's orders: -4/11/2018- Nothing by mouth (NPO) -10/16/2018- oral care two times a day -4/6/2023- peridex solution (germicidal mouthwash) give 15 milliliters (ML) orally two times daily, SWAB twice daily for oral care. Record review of the May 2024 Medication Administration Record revealed the peridex mouthwash medication was administered on 5/22/2024 at 4:00 PM by Registered Nurse, Staff A. Record review of the May 2024 Treatment Administration Record (TAR) revealed the oral care was signed off as administered on the evening shift by Staff A. Record review of a staff witness statement authored by Staff A, revealed that she performed oral care for the resident by moistening a mouth swab with water. Additional review revealed she acknowledged that she did not utilize suction for the resident. Record review revealed a provider progress note dated 5/24/2024 at 3:11 PM which revealed in part, .Reportedly on the night of the 22nd of 3-11 shift the patient's nurse forced mouthwash into the patient's mouth quoted as 'shocked' as well as pried open my mouth she did not suction. Patient states that [s/he] swallowed it .will obtain chest x-ray .Patient history of locked-in syndrome. [s/he] is able to blink [his/her] eyes only. [s/he] is unable to voice any concerns. [s/he] is a letter board for communication . During a surveyor interview with Staff A on 5/29/2024 she acknowledged she did not use suction during mouth care for the Resident ID #1. She further revealed that if she utilized mouthwash her normal practice would be to suction the resident. Furthermore, she revealed she had never worked on a unit with tracheostomy/ventilator residents, and she did not receive education from the facility prior to the incident or before providing oral care to a resident with a tracheostomy. During a surveyor interview on 5/29/2024 at 10:40 AM with the Administrator she revealed that it is her expectation that when providing oral care to a resident who is NPO that suction should be used. Additionally, she was unable to provide evidence that Staff A received training relative to oral care and suctioning of NPO residents who have a tracheostomy prior to providing care on the Ventilator Unit. 2. Record review revealed Resident ID #4 was readmitted to the facility in August of 2019 with diagnoses including, but are not limited to, persistent vegetative state, anoxic brain damage (injury caused by lack of oxygen to the brain), quadriplegia and tracheostomy. Record review of a care plan revised on 6/24/2022 revealed a focus care area for enteral feeding (a way of delivering nutrition directly to your stomach) due to dysphagia (difficulty swallowing) with interventions including, but not limited to, mouth care daily and nothing by mouth. Further review of the care plan revealed a focus care area revised on 6/24/2022 indicating the resident is at risk for alteration in respiratory status related to tracheostomy with interventions including, but not limited to, suction tracheostomy and airway as needed. Record review revealed the following physician's orders: -7/1/2022, oral care two times a day -7/1/2022, NPO 3. Record review revealed Resident ID #5 was readmitted to the facility in May of 2024 with diagnoses including, but not limited to, dysphagia, chronic respiratory failure with hypoxia, quadriplegia, and tracheostomy. Record review of a care plan revised on 3/13/2023 revealed a focus care area for impaired swallowing related to stroke, tracheostomy and ventilator with interventions including, but not limited to, remain NPO until speech determines otherwise. Record review revealed the following physician's orders: -6/20/2023, NPO -6/20/2024, oral care every day and evening shift 4. Record review revealed Resident ID #6 was admitted to the facility in April of 2024 with diagnoses including, but not limited to, persistent vegetative state, acute respiratory failure with hypoxia, anoxic brain damage, quadriplegia, and tracheostomy. Record review of a care plan dated 5/7/2024 revealed a focus care area for impaired swallowing related to anoxic brain injury, tracheostomy dependent with interventions including, but not limited to, monitor for sign/symptoms of aspiration for example coughing, watery eyes, choking and moist sounding voice. Record review revealed the following physician's orders: -4/29/2024, NPO -4/29/2024, oral care every day and evening shift 5. Record review revealed Resident ID #7 was readmitted to the facility in April of 2024 with diagnoses including, but not limited to, dysphagia, acute respiratory failure with hypoxia and tracheostomy. Record review of a care plan dated 5/22/2024 revealed a focus care area for respiratory complications related to tracheostomy with interventions to keep ambu bag (device to provide manual ventilation) and extra tracheostomy tube at bedside. Record review revealed the following physician's orders: -5/22/2024, NPO -5/22/2024, oral care every day and evening shift 6. Record review revealed Resident ID #8 was readmitted to the facility in July of 2023 with diagnoses including, but not limited to, dysphagia, acute respiratory failure with hypoxia and tracheostomy. Record review of a care plan dated 7/24/2023 revealed a focus care area for impaired swallowing related to dysphagia with an intervention including, but not limited to, monitor for signs and symptoms of aspiration. Record review revealed the following physician's orders: -11/10/2023, NPO -7/20/2023, oral care two times a day 7. Record review revealed Resident ID #9 was readmitted to the facility in March of 2024 with diagnoses including, but not limited to, dysphagia, persistent vegetative state, acute respiratory failure with hypoxia, anoxic brain damage and tracheostomy. Record review of a care plan dated 9/27/2022 revealed a focus care area for risk for oral care problems as evidenced by NPO status, teeth were suctioned from resident's esophagus in the hospital with intervention including, but not limited to, oral hygiene/mouth care twice per day. Further review revealed a care plan dated 9/27/2022 with a focus care area that the resident exhibits alteration in respiratory status related to ventilator use with an intervention including, but not limited to, suction airway as needed. Record review revealed the following physician's orders: -9/28/2022, NPO -9/27/2022, oral care two times a day 8. Record review revealed Resident ID #10 was readmitted to the facility in March of 2024 with diagnoses including, but are not limited to, dysphagia, locked in state, acute respiratory failure with hypoxia, anoxic brain damage and tracheostomy. Record review revealed a care plan dated 5/11/2023 with a focus care area indicating the resident is at risk for respiratory complications related to tracheostomy use with interventions including, but not limited to, observe, and report any secretions for color, amount, and odor. Record review revealed the following physician's orders: -5/17/2023, NPO -5/11/2023, oral care two times a day 9. Record review revealed Resident ID #11 was readmitted to the facility in April of 2024 with diagnoses including, but not limited to, dysphagia, chronic respiratory failure with hypoxia and tracheostomy. Record review of a care plan dated 8/22/2022 revealed a focus care area indicating the resident is at risk for impaired swallowing related to dysphagia with an intervention including, but not limited to, monitor for signs and symptoms of aspiration. Further review revealed a care plan dated 5/2/2024 with a focus care area related to tracheostomy use with an intervention including, but not limited to, monitor for airway obstruction/thickened secretions. Record review revealed the following physician's orders: -4/24/2024, NPO -4/24/2024, oral care two times a day -4/24/2024, suction two times per day and as needed 10. Record review revealed Resident ID #12 was readmitted to the facility in August of 2022 with diagnoses including, but are not limited to, dysphagia, chronic respiratory failure with hypoxia and tracheostomy. Record review of a care plan dated 8/22/2022 revealed a focus care area indicating the resident exhibits alteration in respiratory status related to a tracheostomy and ventilator use with interventions including, but not limited to, monitor for sign/symptoms of aspiration for example coughing, watery eyes, choking and moist sounding voice. Further review revealed a care plan dated 5/2/2024 with a focus care area related to tracheostomy use with an intervention including, but not limited to, monitor for airway obstruction/thickened secretions. Record review revealed the following physician's orders: -5/17/2023, NPO -5/11/2024, oral care two times a day 11. Record review revealed Resident ID #13 was readmitted to the facility in May of 2024 with a diagnosis including, but not limited to, chronic respiratory failure with hypoxia. Record review failed to reveal evidence of a care plan related to his/her respiratory status. Record review revealed the following physician's order: -5/28/2024, NPO Further review of the physician's orders failed to reveal evidence of an order for mouth care. 12. Record review revealed Resident ID #14 was readmitted to the facility in May of 2024 with diagnoses including, but not limited to, dysphagia, chronic respiratory failure with hypoxia and tracheostomy. Record review of a care plan dated 2/2/2023 revealed a focus care area that the resident exhibits alteration in respiratory status related to tracheostomy and ventilator use with interventions including, but not limited to, aspiration precautions, monitoring for airway obstruction and thickened secretions. Record review revealed the following physician's orders: -2/2/2023, NPO -2/2/2023, oral care two times a day 13. Record review revealed Resident ID #15 was readmitted to the facility in May of 2024 with diagnoses including, but are not limited to, dysphagia, chronic respiratory failure with hypoxia, tracheostomy, and dependence on a ventilator. Record review of a care plan dated 5/14/2024 revealed a focus care area that the resident exhibits alteration in respiratory status related to tracheostomy and ventilator use with interventions including, but not limited to, aspiration precautions, and monitor for airway obstruction and thickened secretions. Record review revealed the following physician's order: -5/13/2024, NPO Further review of the physician's orders failed to reveal evidence of an order for mouth care. 14. Record review revealed Resident ID #16 was readmitted to the facility in March of 2021 with diagnoses including, but not limited to, persistent vegetative state, chronic respiratory failure with hypoxia, anoxic brain damage and tracheostomy. Record review of a care plan dated 3/30/2021 revealed a focus care area, indicating the resident is at risk for respiratory complications related to tracheostomy with interventions including, but not limited to, during apnea (absence of breathing) observe the resident's color and assess consciousness, and report to the physician and suction trach/airway as needed. Record review revealed the following physician's orders: -3/30/2021, NPO -3/30/2021, oral care every day and evening shift 15. Record review revealed Resident ID #17 was readmitted to the facility in April of 2024 with diagnoses including, but not limited to, persistent vegetative state, dysphagia, chronic respiratory failure with hypoxia and tracheostomy. Record review of a care plan dated 5/14/2024 revealed a focus care area that indicating the resident exhibits alteration in respiratory status related to tracheostomy and ventilator use with interventions including, but not limited to, aspiration precautions, and monitor for airway obstruction and thickened secretions. Record review revealed the following physician's orders: -11/3/2021, NPO -4/12/2024, oral care every shift Record review of a facility provided document indicated that the following Nursing Assistants worked on the Ventilator Unit. During a surveyor interview on 5/29/2024 at approximately 10:15 AM with Nursing Assistant (NA), Staff C, she revealed that she uses an oral tray kit attached to suction to provide oral care for residents with a tracheostomy who are NPO. During a surveyor interview on 5/29/2024 at 10:25 AM with NA, Staff D, she revealed that she uses an oral tray kit attached to suction to provide oral care for residents who are NPO. Additionally, she revealed she had not received any training on how to use the oral tray kit with suction. During a surveyor interview on 5/29/2024 at approximately 10:30 AM with NA, Staff E, she revealed that she uses an oral tray kit attached to suction to provide oral care for all residents who are NPO. During a surveyor interview on 5/29/2024 at 11:00 AM with NA, Staff F, she revealed it is her practice to use either an oral tray kit or wall suction during oral care for the residents. During a surveyor interview on 5/29/2024 at 11:11 AM with NA, Staff G, she revealed it is her practice to use oral tray kits with suctioning for oral care. During a surveyor interview on 5/29/2024 at 11:34 AM, with NA, Staff H, she revealed she uses oral tray kits attached to wall suction for NPO residents. During a surveyor interview on 5/30/2024 at 1:34 PM with the Medical Director, he revealed he was not aware that NA's were performing oral care with suction. He further revealed that it would be his expectation that oral care with suction would only be provided by a licensed nurse or respiratory therapist. During a surveyor interview on 5/30/2024 at approximately 2:20 PM with the Respiratory Therapist Manager, she revealed that most residents on the ventilator unit have artificial airways. She further revealed that only licensed nurses or respiratory therapists should be performing oral care with suctioning. During surveyor interviews on 5/29/2024 at 10:40 AM and 5/30/2024 at approximately 5:00 PM with the Administrator, she acknowledged that NA's were providing suctioning during oral care to those residents on the Ventilator Unit who were NPO and had tracheotomies and it was not within the NA scope of practice to suction Additionally;y, she acknowledged that the facility does not have a policy or procedure on how to perform oral care on residents with a tracheostomy. Due to the facility's failure to provide oral care consistent with professional standards of practice Residents ID #s 1, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17 were placed at risk for serious injury, serious harm, serious impairment, or death. Cross Reference F 725

Based on record review and staff interview it has been determined that the facility failed to provide treatment and care in accordance with professional standards of practice, relative to promptly identifying and intervening during an acute change in a resident's condition, for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to The Rhode Island Department of Health on 5/21/2024 alleges, Resident ID #1 had a new wound to his/her toe. Further review revealed the Physician's Assistant (PA) wanted to hospitalize the resident however, the facility administration refused to send the resident to the hospital. Review of a facility policy titled, Skin integrity and wound management review date 5/1/2024 states in part, .A comprehensive initial and ongoing nursing assessment of intrinsic and extrinsic factors that influence skin health, skin/wound impairment, and the ability of wound to heal will be performed. The plan of care for the patient will be reflective of assessment finding from the comprehensive patient assessment and wound evaluation. Staff will continually observe and monitor patients for changes and implement revision to the plan of care as needed . Record review revealed that Resident ID #1, was admitted to the facility in September of 2023 with diagnoses including, but not limited to, atrial fibrillation (an irregular often rapid heart rate that commonly causes poor blood flow) and peripheral vascular disease (circulatory disease in which narrowed blood vessels reduce blood flow to the limbs). Review of a change in condition form dated 5/18/2024 at 1:00 PM authored by Licensed Practical Nurse, (LPN) Staff A, revealed that on the 7:00 AM to 3:00 PM shift the resident was observed with new wounds to the his/her left great toe and left inner ankle. Additional review revealed that the resident complained of 7 of 10 pain to the toe and 4 of 10 pain to the left inner ankle. Further the resident was experiencing one plus pitting edema (indention when touched) to his/her lower extremities. Additional review of the change in condition form revealed a new order for a STAT (as soon as possible) Xray to the Left toes. Record review of the progress notes revealed the following: -5/19/2024 at 7:54 AM, Nursing notified the covering Nurse Practitioner that the x-ray to the left toes was negative for fracture. New order monitor for signs and symptoms of injury. -5/20/2024 at 6:25 AM, The resident was alert with intermittent confusion and continued with pitting edema to both lower extremities. -5/20/2024 at 2:23 PM, Resident was evaluated by the PA, new order for STAT venous and arterial ultrasound of the left foot to rule out vascular compromise. Record review revealed a physician order dated 5/20/2024 for a STAT arterial and venous ultrasound to his/her right foot. Record review failed to reveal evidence that the above-mentioned ultrasound was completed. Record review revealed a physician's order dated 5/21/2024 for an additional STAT arterial and venous ultrasound for the resident's bilateral feet. Additional review of the progress notes revealed the following: -5/21/2024 at 1:46 PM, authored by the PA, Staff B, revealed the nursing staff was instructed if unable to obtain the ultrasound in a reasonable amount of time STAT the resident should be sent to the emergency room immediately. Additionally, nursing staff was instructed to apply compression stockings. Further review revealed patient has a history of congestive heart failure monitor patient progress should edema persist will order blood work. Awaiting ultrasound. Record review failed to reveal evidence of a physician's order to apply compression stockings. Further record review of the progress notes revealed the following: -5/21/2024 at 1:11 PM, PA notified that after four hours the STAT ultrasound had not been completed. -5/21/2024 at 8:10 PM, Authored by LPN, Staff C, revealed in part, Alert. Confused. Venous U/S [ultrasound] obtained to BLE [bilateral lower extremities] at approximately 5:00 PM .left toes remain purple in color. Right toes lighter purple/pink. BLE cool to touch from knee to feet. Faint PP [pedal pulses felt in the feet] bilat. [Both legs]. BPE [bilateral peripheral edema] noted .Right- lower extremity color is pale. Left-lower extremity color is pale. Right LE is cool to touch. Left lower LE is cool to touch . During a surveyor interview on 5/23/2024 at approximately 11:30 AM with Staff C, she acknowledged she completed the above-mentioned assessment for the resident. Additionally, she revealed she did not notify the provider of the resident exhibiting the above mentioned symptoms. Record review of a progress note dated 5/22/2024 at 6:56 AM authored by LPN, Staff E, revealed in part, .Still awaiting interpretation of venous ultrasound. Left toes remain purple in color. Right toes lighter purple/ pink. BLE cool to touch from knees to feet. Faint PP bilat . During a surveyor interview on 5/23/2024 at approximately 11:30 AM with LPN, Staff E, she acknowledged she completed the above-mentioned assessment for the resident on 5/21/2024. She further revealed she was aware that only a venous ultrasound was completed for the resident. She acknowledged she did not notify the provider of the resident experiencing the above-mentioned symptoms and that the arterial ultrasound has not been completed. During a surveyor interview on 5/23/2024 at 11:48 AM with Physician Assistant, Staff B, he acknowledged the order he entered on 5/20/2024 for the ultrasound to the resident's right foot was erroneous and it should have been written for the residents left foot. Additionally, he revealed that he would have expected notification of the resident's change in condition as documented on 5/21/2024 on 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM. During a surveyor interview on 5/22/2024 at approximately 2:30 PM with the Director of Nursing Services (DNS), she revealed she would expect the resident would be assessed every shift for 72 hours, including a full set of vital signs after a change in condition is identified per policy. Additionally, acknowledged she was the nurse on duty on 5/20/2024 during the 7:00 AM and 3:00 PM and 3:00 PM to 11:00 PM shift and she did not complete a full assessment and did not obtain the residents vital signs. Furthermore she was unable to provide evidence why the ultrasound was not completed as ordered on 5/20/2024. Record review failed to reveal evidence of an assessment completed to include complete vital signs on the following dates and times: - 5/18/2024 3:00 PM to 11:00 PM - 5/19/2024 3:00 PM to 11:00 PM - 5/20/2024 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM Record review of a progress note dated 5/22/2024 at 8:00 AM, authored by RN, Staff A, revealed that the resident was sent to the emergency room related to worsening discoloration of both lower extremities with faint pedal pulses and both extremities cool to touch. Record review of a Radiology Results Report dated 5/22/2024 at 11:17 AM failed to reveal evidence that the arterial ultrasound to both feet was completed as ordered. During a surveyor interview on 5/23/2024 at 2:45 PM with the Medical Director, he revealed his expectation would be that the PA order would reflect the ultrasound to have been ordered for the correct foot on 5/20/2024. Additionally, he revealed he would have expected both the arterial and venous ultrasound to the resident bilateral feet to have been completed as ordered. Record review of the ED [Emergency Department] Documentation dated 5/22/2024 at 9:06 AM revealed that the resident had been transferred to the hospital by Emergency Medical Services (EMS) after worsening foot discoloration and swelling of his/her left and right feet. Both extremities were cool to touch, the left foot red/purple and right foot bluish purple in color. Wounds were noted to the right outer ankle and left inner ankle with three plus pitting edema. Review of the hospital documentation titled, History and Physical dated 5/22/2024 at 7:17 PM, revealed the following upon arrival to the hospital: -Blood Pressure (BP):129/94 (normal range 120/80) -Pulse (P): 111 (normal range 60-100) -Respiratory Rate (RR): 20 (normal range 12-16) -White Blood Cells (WBC): 15.9 (normal range 4.0-11.0) Further record review revealed a plan including, but not limited to, suspect resident presentation likely due to peripheral embolization (state in which the blood vessel is obstructed by the lodgment of a material or mass),versus cellulitis, start heparin drip for suspected embolization,start antibiotics for treatment of acute cellulitis of left lower extremity with associated bacteremia(bacteria in the blood) related to tachycardia (elevated heart rate) and leukocytosis (higher than normal level of white blood cells) During a surveyor interview on 5/23/2024 at 12:29 PM with the DNS she was unable to provide evidence that the staff completed an assessment including a full set of vital signs every shift for 72 hours after a change in condition was identified on 5/18/2024. Additionally, she was unable to provide evidence that the provider was notified after the resident's change in condition as documented on 5/21/2024. Furthermore, she was unable to explain why the arterial ultrasound was not obtained as ordered prior to the residents hospitalization on [DATE].

Based on record review and staff interview it has been determined that the facility failed to provide sufficient nurse staffing to ensure resident safety and attain the highest practicable physical, mental and psychosocial wellbeing of each resident relative to 1 of 1 unlicensed person who was scheduled as a nurse on a unit unsupervised and who documented that she administered treatments and/or medications to 5 of 5 residents reviewed who had treatments and/or medications scheduled for the 11:00 PM - 7:00 AM shift, Resident ID #s 1, 2, 3, 4, and 5, and who documented in 34 of 34 residents' health records reviewed from a unit, Resident ID #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33 and 34. Additionally, the facility failed to provide sufficient nurse staffing relative to 1 of 1 Registered Nurses (RN), Staff C, reviewed who worked 20 hours in a 24 hour period. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 5/7/2024, alleged that an unlicensed graduate nurse had administered medications to residents on the N3(north) unit of the facility on the 11:00 PM-7:00 AM shift. According to RegisteredNursing.org, In addition to attending and successfully completing recognized nursing schools, nurses must pass the National Council Licensure Examination-Registered Nurse (NCLEX-RN) exam in order to work as a practicing Registered Nurse .Candidates must pass NCLEX within three years from when they graduated nursing school .some states put additional limitations on how many times candidates can re-take the test . Review of the working nursing schedule on 5/4/2024, revealed the scheduled nurse on the North 3 unit called out for the 11:00 PM-7:00AM shift and Unlicensed Person, Staff A, was scheduled as the registered nurse on the unit, unsupervised. Record review revealed Staff A, graduated from a nursing school in 2016 and does not hold an active nursing license. 1a. Record review revealed Resident ID #1 was admitted to the facility in January of 2023 with diagnoses including, but not limited to, chronic respiratory failure, pneumonia, and a tracheostomy. Record review revealed the resident had a gastrostomy tube (G-tube - a surgically inserted tube that goes through the abdomen directly into the stomach) to administer feedings and medications. Record review of the May 2024 Medication Administration Record (MAR) revealed Staff A, documented that she administered the following medications on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 to Resident ID #1: - 6:00 AM- Acetylcysteine Solution 10% 2 milliliter (ml) via trach (tracheostomy) - 6:00 AM- Albuterol Sulfate Nebulization solution 0.083% via trach - 6:00 AM- TwoCal HN (tube feeding) administer bolus via gravity 240 ml - Flush tube (G-Tube) with 30 ml of water before and after each medication pass - 6:00 AM- Flush tube with 180 ml (water) - Oxygen via trach mask to maintain oxygen saturation of 88%-92% - Check tube (G-tube) for proper placement prior to each feeding, flush, or medication administration by measuring the length of the tube 1b. Record review revealed Resident ID #2 was admitted to the facility in May of 2021 with diagnoses including, but not limited to, dementia, chronic obstructive pulmonary disease (COPD), diabetes type 2 and a history of falling. Record review of the May 2024 MAR revealed Staff A documented that she administered the following medication on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 to Resident ID #2: -2:00 AM and 6:00 AM- Morphine Sulphate (a medication used to treat severe pain) oral solution 5 milligram (mg) by mouth Review of the Narcotic Book revealed Staff A documented that she administered the above medication on 5/5/2024 at 2:00 AM and 6:00 AM. 1c. Record review revealed Resident ID #3 was admitted to the facility in July of 2021 with diagnoses including, but not limited to, dementia and anxiety disorder. Record review of the May 2024 MAR revealed Staff A documented that she administered the following medication on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 to Resident ID #3: -7:00 AM- Trazodone (a medication used to treat depression) 75 mg 1d. Record review revealed Resident ID #4 was admitted to the facility in July of 2016 with diagnoses including, but not limited to, dementia and bipolar disorder. Record review of the May 2024 MAR revealed Staff A documented that she administered the following medication on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 to Resident ID #4: -6:00 AM- Tramadol (a medication used to treat pain) 50 mg Further record review revealed Staff A documented that she assessed the resident for side effects of psychotherapeutic medications. 1f. Record review revealed Resident ID #5 was admitted to the facility in July of 2021 with diagnoses including, but not limited to, dementia and a history of falling. Record review of the May 2024 Treatment Administration Record (TAR) revealed Staff A, documented that she administered the following treatment on the 11:00- PM - 7:00 AM shift on 5/4-5/5/2024 to Resident ID #5: -Lotrisone Cream 1-0.05% (Clotrimazole-Betamethasone) apply to right lower extremity rash topically every shift for rash 1g. Record review revealed Resident ID #6 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, dementia and chronic congestive heart failure. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including pain. 1h. Record review revealed Resident ID #7 was admitted to the facility in April of 2024 with diagnoses including, but not limited to, dementia and anxiety disorder. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00- PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to, pain and shortness of breath. 1i. Record review revealed Resident ID #8 was admitted to the facility in March of 2017 with diagnoses including, but not limited to, dementia and chronic congestive heart failure. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to, shortness of breath. 1j. Record review revealed Resident ID #9 was admitted to the facility in March of 2021 with diagnoses including, but not limited to, dementia and anxiety disorder. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to, pain and shortness of breath. 1k. Record review revealed Resident ID #10 was admitted to the facility in December of 2023 with diagnoses including, but not limited to, dementia and a history of falling. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to, shortness of breath. 1L. Record review revealed Resident ID #11 was admitted to the facility in September of 2019 with diagnoses including, but not limited to, dementia and muscle weakness. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to pain and shortness of breath. 1m. Record review revealed Resident ID #12 was admitted to the facility in February of 2022 with diagnoses including, but not limited to, dementia and major depressive disorder. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to pain and shortness of breath. 1n. Record review revealed Resident ID #13 was readmitted to the facility in August of 2022 with diagnoses including, but not limited to, dementia and COPD. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to pain and shortness of breath. 1o. Record review revealed Resident ID #14 was readmitted to the facility in February of 2022 with diagnoses including, but not limited to, dementia and a history of falling. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to, pain and shortness of breath. 1p. Record review revealed Resident ID #15 was readmitted to the facility in March of 2015 with diagnoses including, but not limited to, dementia and COPD. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to, pain ans shortness of breath. 1q. Record review revealed Resident ID #16 was admitted to the facility in March of 2023 with diagnoses including, but not limited to, dementia and COPD. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to, pain and shortness of breath. 1r. Record review revealed Resident ID #17 was readmitted to the facility in December of 2023 with diagnoses including, but not limited to, dementia and anxiety disorder. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to, pain and shortness of breath. 1s. Record review revealed Resident ID #18 was readmitted to the facility in February of 2022 with diagnoses including, but not limited to, dementia and a history of falling. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to, pain and shortness of breath. 1t. Record review revealed Resident ID #19 was readmitted to the facility in April of 2024 with diagnoses including, but not limited to, dementia and epilepsy. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to, pain and shortness of breath. Additionally, Staff A documented that she assessed the resident for adverse side effects of psychotherapeutic medications. 1u. Record review revealed Resident ID #20 was admitted to the facility in May of 2023 with diagnoses including, but not limited to, dementia and psychotic disorder. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to, pain and shortness of breath. Additionally, Staff A documented that she assessed the resident for adverse side effects of psychotherapeutic medications. 1v. Record review revealed Resident ID #21 was admitted to the facility in March of 2019 with diagnoses including, but not limited to, dementia and chronic heart failure. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to, pain and shortness of breath. Additionally, Staff A documented that she assessed the resident for adverse side effects of psychotherapeutic medications. 1w. Record review revealed Resident ID #22 was admitted to the facility in February of 2020 with diagnoses including, but not limited to, dementia and epilepsy. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to, pain and shortness of breath. 1x. Record review revealed Resident ID #23 was admitted to the facility in February of 2023 with diagnoses including, but not limited to, dementia and major depressive disorder. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to, pain and shortness of breath. 1y. Record review revealed Resident ID #24 was readmitted to the facility in February of 2022 with diagnoses including, but not limited to, dementia and COPD. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to, pain and shortness of breath. Additionally, Staff A documented that she assessed the resident for adverse side effects of psychotherapeutic medications. 1z. Record review revealed Resident ID #25 was readmitted to the facility in December of 2023 with diagnoses including, but not limited to, dementia and anxiety disorder. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to pain, and shortness of breath. 1aa. Record review revealed Resident ID #26 was admitted to the facility in June of 2023 with diagnoses including, but not limited to, dementia and anxiety disorder. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to, pain and shortness of breath. Additionally, Staff A documented that she assessed the resident for adverse side effects of psychotherapeutic medications. 1ab. Record review revealed Resident ID #27 was admitted to the facility in July of 2022 with diagnoses including, but not limited to, dementia and diabetes type 2. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to, pain and shortness of breath. Additionally, Staff A documented that she assessed the resident for adverse side effects of psychotherapeutic medications. 1ac. Record review revealed Resident ID #28 was readmitted to the facility in February of 2022 with diagnoses including, but not limited to, dementia and diabetes type 2. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to, pain and shortness of breath. Additionally, Staff A documented that she assessed the resident for adverse side effects of psychotherapeutic medications. 1ad. Record review revealed Resident ID #29 was admitted to the facility in January of 2024 with diagnoses including, but not limited to, dementia and diabetes type 2. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to, pain and shortness of breath. 1ae. Record review revealed Resident ID #30 was readmitted to the facility in November of 2023 with diagnoses including, but not limited to, dementia and anxiety disorder. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to, pain and shortness of breath. Additionally, Staff A documented that she assessed the resident for adverse side effects of psychotherapeutic medications. 1af. Record review revealed Resident ID #31 was readmitted to the facility in March of 2022 with diagnoses including, but not limited to, dementia and diabetes type 2. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to, pain and shortness of breath. Additionally, Staff A documented that she assessed the resident for adverse side effects of psychotherapeutic medications. 1ag. Record review revealed Resident ID #32 was admitted to the facility in August of 2021 with diagnoses including, but not limited to, dementia and COPD. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to, pain and shortness of breath. Additionally, Staff A documented that she assessed the resident for adverse side effects of psychotherapeutic medications. 1ah. Record review revealed Resident ID #33 was readmitted to the facility in February of 2022 with diagnoses including, but not limited to, dementia and diabetes type 2. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to, pain and shortness of breath. Additionally, Staff A documented that she assessed the resident for adverse side effects of psychotherapeutic medications. 1ai. Record review revealed Resident ID #34 was readmitted to the facility in December of 2023 with diagnoses including, but not limited to, dementia and a history of falling. Record review revealed Staff A documented in the May 2024 MAR and TAR on the 11:00 PM - 7:00 AM shift on 5/4-5/5/2024 various assessments including, but not limited to, pain and shortness of breath. During a surveyor interview on 5/9/2024 at 10:27 AM with the 11:00 PM - 7:00 AM shift nursing supervisor, Staff B, she indicated that Unlicensed Person, Staff A worked on the N3 unit on 5/4/2024 into 5/5/2024 as the nurse on the unit, due to a call out. Staff B indicated that there are approximately 34 residents on the unit. Additionally, she indicated that she was aware that Staff A was not a licensed nurse. During a surveyor interview on 5/9/2024 at 12:01 PM with Registered Nurse, Staff C, she indicated that on the 11:00 PM - 7:00 AM shift on 5/4/2024 into 5/5/2024 she worked on the South 1 unit. She further indicated that she went up to the N3 unit once during that shift, at approximately 5:30 AM, to help Staff A with medication administration. Additionally, she indicated that she administered medications to three or four residents, however, she was unable to provide evidence that she was the one who administered the medications to the residents on N3 from 11:00 PM to 7:00 AM on 5/4 into 5/5/2024. During a surveyor interview on 5/9/2024 at 3:21 PM with Staff A, she indicated that she is a graduate nurse and not a licensed nurse. She acknowledged that she worked on the N3 unit unsupervised on the 11:00 PM - 7:00 AM shift on 5/4/2024 into 5/5/2024, and documented in the resident's medical records that she administered medications, treatments, and completed assessments. Additionally, she indicated that she was not the one to administer the medications to the residents and that another nurse, whose name she could not recall, came to the unit at approximately 6:00 AM to administer the medications as ordered. Furthermore, she acknowledged that she documented in the 34 resident records that she assessed residents, administered medications and provided treatments to them. During a surveyor interview on 5/10/2024 at approximately 1:00 PM with the Director of Nursing Services (DNS) she indicated that she was unaware that Staff A was scheduled to work unsupervised as the nurse on the unit until after the shift was completed. She further indicated that she was unaware that Staff A had graduated nursing school 8 years ago and was ineligible to work as a graduate nurse. Additionally, she acknowledged that Staff A, an unlicensed person, documented that she administered medications and/or treatments to Resident ID #s 1, 2, 3, 4, and 5. Furthermore, she acknowledged that Staff A, documented in the 34 resident records that she assessed residents, administered medications and provided treatments to them. 2. Review of a community reported complaint submitted to the Rhode Island Department of Health on 5/13/2024 alleged in part, that a nurse was forced to work a 20 hour shift. According to the 2023 Rhode Island General Laws Title 23 - Health and Safety Chapter 23-17.20- Healthcare Facilities Staffing Section 23-17.20-3. - Overtime requirement, .(b) .In no case shall a health care facility require an employee to work in excess of twelve (12) consecutive hours . Review of the facility's working schedule for 5/10/2024 through 5/11/2024 revealed Registered Nurse, Staff C, worked the following consecutive days and shifts: -5/10/2024- N3 Unit- 7:00 PM- 11:00 PM -5/10-5/11/2024- South 1 Unit- 11:00 PM-7:00 AM -5/11/2024- North 1 Unit- 7:00 AM- 3:00 PM Additional review revealed RN, Staff C worked on the units for a total of 20 hours in a 24 hour period. During a surveyor interview on 5/13/2024 at approximately 9:00 AM with Staff C, she revealed that on 5/10/2024 she was scheduled to work in the facility as a unit nurse from 7:00 PM until 7:00 AM on 5/11/2024, a 12 hour shift. She indicated that she was asked by a supervisor to stay on a different unit until 11:00 AM on 5/11/2024 due to a call out. She further indicated that the oncoming nurse did not come in to relieve her from the unit and she worked until 3:00 PM, to include administering medications to residents. RN, Staff C, she indicated that she did not want to work for more than 16 hours however, she did not want to leave the residents abandoned. She was also worried that her nursing license would be in jeopardy if she had left. During a surveyor interview on 5/13/2024 at 9:28 AM with the Staffing Coordinator, she revealed that she is responsible for creating the nursing schedule. She further indicated that the facility cannot sufficiently staff the units with nursing staff without using agency staff. Additionally, she indicated that the facility offers increased wages for facility staff nurses to pick up unfilled shifts however, sufficiently staffing the facility is still difficult. During a surveyor interview on 5/14/2024 at 9:38 AM with the Nursing Weekend Supervisor, Staff D, she indicated that she was the nursing supervisor on the weekend of 5/11/2024 however worked on the unit due to insufficient staffing. She further indicated that RN, Staff C was scheduled to work until 11:00 AM on 5/11/2024, however when a nurse called out that morning, she requested Staff C to stay on the until 3:00 PM. Additionally, she indicated that she is responsible for staffing the units on the weekends if needed, however she was unaware that Staff C had already worked 16 hours prior to asking her to stay for an additional 4 hours. During surveyor interviews on 5/13/2024 at 9:53 AM and on 5/14/2024 at 9:51 AM with the DNS, she acknowledged that Staff C worked as a unit nurse, to include administering medications to residents, for 20 hours in a 24 hour period. Additionally, she was unable to provide evidence that the facility provided sufficient nurse staffing to ensure resident safety and attain the highest practicable physical, mental and psychosocial wellbeing of each resident.

Based on record review and staff interview it has been determined that the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident relative to 1 of 1 unlicensed person who was working as a Graduate Nurse, (GN), in the facility and was responsible for overseeing the care of 34 of the facility's residents during the 11:00 PM - 7:00 AM shift on 5/4/2024- 5/5/2024, Staff A. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 5/7/2024 alleged that an unlicensed graduate nurse administered medications to residents on the N3 (north) unit of the facility on the 11:00 PM - 7:00 AM shift. Record review of Staff A's personnel file failed to reveal evidence that she had a valid nursing license. Additional review failed to reveal evidence that the facility provided nursing education or completed nursing competencies for Staff A Record review revealed Staff A worked unsupervised on the 11:00 PM - 7:00 AM shift on 5/4/2024-5/5/2024 and documented in 34 residents' electronic medical records to include, but not limited to, the administration of medications, treatments, and completion of assessments. During a surveyor interview with the Director of Nurses on 5/9/2024 at approximately 3:30 PM, she was unable to provide evidence that Staff A had a nursing license and acknowledged that she was the designated nurse who was left unsupervised to work independently on the 11:00 PM - 7:00 AM shift on 5/4/2024, to oversee the care of 34 of the facility's residents. During a surveyor interview with the Administrator on 5/10/2024 at approximately 1:00 PM, she acknowledged that Staff A was an unlicensed person who worked unsupervised as a nurse on the above mentioned shift and date, and documented in 34 residents' electronic medical records to include, but not limited to, the administration of medications, treatments, and completion of assessments. Additionally, she was unable to provide evidence that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Cross reference F 725

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents that are fed through a feeding tube receive the appropriate treatment and services to prevent complications for 1 of 1 resident reviewed who receives nutrition and medications via Gastrostomy Tube (G-tube- is a feeding tube that provides supplemental feeding, hydration, or medicine directly to the stomach), Resident ID #21. Findings are as follows: Record review of a facility policy, revised on 6/1/2021, titled, Gastrostomy Tube (G-tube)/Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement, states in part, .Document .Procedure .Site assessment .Patient's response, including any adverse effects .X-ray confirmation . Record review for the resident revealed s/he was admitted to the facility in April of 2023 with diagnoses including, but not limited to severe protein-calorie malnutrition resulting in gastrostomy tube placement. Record review reveals this resident is NPO (nothing by mouth). During the initial tour on 4/2/2024 at approximately 8:45 AM the resident was lying in bed with his/her eyes closed, non-verbal and s/he did not respond to the surveyor when she introduced herself. Review of a progress note, dated 4/2/2024 at 9:12 PM, revealed the resident's G-tube dislodged when a nurse attempted to flush it during medication administration. Further review of the notes revealed a physician's order on 4/2/2024 to insert a G-tube and obtain a STAT (immediately) KUB (x-ray to view the kidneys, ureters, and bladder) with Gastrografin (a contrast medium used for diagnostic examination of the gastrointestinal tract). Review of the KUB results, dated 4/3/2024 at 12:29 PM, failed to provide verification of the G-tube placement. Further record review failed to reveal evidence that, after the facility received the inclusive KUB results, they failed to contact the physician or follow-up with the contracted radiology vendor regarding the inclusive results on 4/3/2024. During a surveyor observation and simultaneous interview on 4/3/2024 at approximately 12:00 PM, with the resident's family member, s/he indicated that s/he was unaware that the resident's G-tube dislodged on 4/2/2024. Additionally, she acknowledged that the resident was grimacing in pain and indicated this is the only way of communicating that s/he is uncomfortable. S/he further revealed that s/he was upset as the resident was unable to receive any medication to alleviate his/her pain as the G-tube placement has yet to be confirmed. During a surveyor interview on 4/3/2024 at 1:56 PM with the Assistant Director of Nursing, she indicated that, although the G-tube was re-inserted, it cannot be used to administer medications, nutrition, or hydration until the proper placement of the G-tube is confirmed. She was unable to provide evidence of interventions that were implemented to address the resident's nutrition, hydration and medication needs while awaiting confirmation of the G-tube placement. Further record review of the progress notes dated 4/4/2024 revealed the following entries: -11:17 AM, Placement x-ray did not mention anything about tube placement so [radiology] was called and waiting on call back. Pt remains in bed with feed off and no meds given . -12:59 PM, Abdomen 1 view was interpreted by [radiologist, through a contracted vendor] again on 4/4 with findings that gastrostomy tube in the stomach . This indicates that the placement of the G-tube was verified, and the resident could resume receiving nutrition, hydration and medications that the resident had gone without for approximately 36 hours. During a surveyor interview on 4/4/2024 at 3:34 PM with Registered Nurse, Staff A, she acknowledged that the resident had not received any medication, nutrition, or hydration since 4/2/2024 at approximately 9:00 PM when his/her G-tube was dislodged. Furthermore, she was unable to explain why the resident's family member was not notified that his/her G-tube became dislodged on 4/2/2024. During a surveyor interview on 4/4/2024 at 4:32 PM with the Physician's Assistant, in the presence of the Interim Director of Nursing Services and the Lead Clinical Specialist, he indicated that he was unaware until the morning of 4/4/2024 that the resident's G-tube had dislodged on 4/2/2024. He stated that he would have expected the staff to follow clinical protocols and re-evaluate the resident. Additionally, he acknowledged that he did not prescribe any additional hydration to the resident who had not received any hydration since 4/4/2024 at approximately 9:00 PM. During a surveyor interview on 4/4/2024 at 4:47 PM with the Interim Director of Nursing Services in the presence of the Lead Clinical Specialist, she was unable to explain why there were no interventions implemented to address his/her hydration, nutrition or medications while the facility was awaiting g-tube placement confirmation. This failure by facility resulted in a non-verbal cognitively impaired resident with the inability to communicate hungry, thirst, pain or medical needs to go without nutrition, hydration, and medications for appropriately 36 hours. 41720

Based on record review, resident representative interview, and staff interview, it has been determined that the facility failed to reconcile all pre-discharge medications with the resident's post-discharge medications, for 1 of 9 discharged residents reviewed, Resident ID #1, and failed to have a discharge summary that includes, but is not limited to, a recapitulation of the resident's stay, a final summary of the residents status at discharge and a reconciliation of the residents medications for 2 of 9 residents reviewed Resident ID #s 6 and 9. Findings are as follows: Record review of the facility's discharge policy titled Discharge Planning Process states in part, All Patients being discharged to home, to an assisted living facility, or another community based setting will be given a Discharge Transition Plan and Discharge Packet. The Discharge Transition Plan must include, but not limited to .A recapitulation of the patient's stay that includes, but is not limited to, diagnoses, course of illness/treatment of therapy, and pertinent lab, radiology, and consultation results .A final summary of the patient's status at the time of discharge that is available for release to authorized persons and agencies .Reconciliation of all pre-discharge medications with the patient's post-discharge medications (both prescription and over-the-counter) .A post-discharge plan of care that is developed with the participation of the patient and, with the patient's consent, the patient representative(s), which will assist the patient to adjust to his/her new living environment .Where the patient plans to reside, any arrangements that have been made for the patient's follow-up care and any post-discharge medical and non-medical services .The Discharge Transition Plan will be reviewed with and given to the patient and/or patient representative along with the Discharge Packet upon discharge . Record review of the facility's discharge policy titled, Discharge with Medications states in part, Discharge with Medications (from the facility) .When a Facility physician/prescriber discharges a resident with the medications remaining in the resident's personal inventory, the Facility nurse should review the medications to be given to the resident with the physician/prescriber .The facility should notify the pharmacy of the list of medications and quantities of medications given to the discharged resident or resident's representative for appropriate billing .A medication release form should be used to record the inventory released upon discharge .The completed medication release form should be placed in the resident's permanent medical record .Facility should reconcile discharge medications to the list of medications taken during the facility stay, per facility policy .Facility staff should review the medication orders and directions for use with the resident or the resident's representative before the resident's Discharge with Medications .The Facility should document this review in the resident's medical record in an appropriate note section or resident education record .The facility should have the resident or responsible party sign for receipt of leave of absence/discharge medications .When discharge medications are taken from the resident's personal inventory, the Facility should chart the following on the MAR .Quantity of each medication given to the resident .Date medication is given to the resident .Time medication is given to the resident .Name of person receiving the medication . Record review of a community complaint reported to the Rhode Island Department of Health on 2/22/2024, alleges Resident ID #1 was sent home with another resident's (Resident ID #2) medications. The complainant, a family member of Resident ID #1, included pictures of the following medication cards with Resident ID #2's name printed on the top: Furosemide 40 milligrams (MG) (a diuretic- adverse effects can include electrolyte depletion and renal failure) Methenamine Hippurate 1 Gram (GM) (used to prevent or control returning urinary tract infections- adverse effects can include- nausea, upset stomach- contraindicated in patients with renal insufficiency) Dexamethasone 4 MG (used to decrease inflammation - adverse effects can include - hyperglycemia, which poses a significant health risk when you have chronic kidney disease (CKD)) Glimepiride 1 MG (used to help control high blood sugar - adverse effect can include - hypoglycemia, which poses a significant health risk when you have CKD) Eliquis 5 MG (used to prevent serious blood clots - adverse effects can include bleeding) Acyclovir 400 MG (used to decrease viral replication related to herpes/varicella infections - Patients with CKD are vulnerable to drug toxicity) Metoprolol Succinate extended release 25 MG (used to lower blood pressure - adverse effects can include increased risk of hypotension, shortness of breath) 1) Record review of Resident ID #1 revealed s/he was readmitted to the facility in July of 2023 with diagnoses including but are not limited to, large B-Cell lymphoma (blood cancer in the lymph nodes), type 2 diabetes mellitus, hypertensive heart and chronic kidney disease without heart failure. The above-mentioned medications have contraindications due to this resident's diagnoses. During a surveyor interview with the family member of Resident ID #1 on 2/23/2024 at approximately 10:25 AM, s/he revealed that s/he went to pick up Resident ID #1 on the discharge date and was given a red bag full of medications by the nurse. The family member further revealed that s/he did not receive discharge education from the nurse regarding the medications. Additionally, the family member stated that when reviewing the medications at home, s/he first thought that the medications must be generics because the medication names on the blister packs failed to match the medications on the facility-provided list of medications for the resident. She stated that eventually she realized that the medications were labeled with Resident ID #2's name and s/he called the facility to inform them that s/he has someone else's medications. Review of a facility document titled Continuity of Care Discharge/Transfer of Patient Form indicated that the resident's medication list was attached to this document. Further review of this document failed to reveal a discharge summary, that it was signed as completed by the discharging nurse, Registered Nurse, Staff A, or that it was signed off as reviewed by the resident or responsible party. During a surveyor interview with Staff A on 2/23/2024 at approximately 9:40 AM he acknowledged that he mistakenly provided Resident ID #2's medications to Resident ID #1 upon his/her discharge. He further revealed that he had 2 red medication bags set up for discharges, he grabbed the wrong one and handed it to the family member of Resident ID #1 without checking first. During a surveyor interview with the Director of Nursing Services (DNS) on 2/23/2024 at approximately 1:00 PM, she was unable to provide evidence that all pre-discharge medications were reconciled with the resident's post-discharge medications prior to Resident ID #1 being discharged home from the facility. 2) Record review of Resident ID #6 revealed s/he was admitted to the facility in December of 2023 with diagnoses including but not limited to, malignant neoplasm of the sigmoid colon (colon cancer) and surgical aftercare following surgery of the digestive system. Review of a progress note dated 12/29/2023 revealed in part, .discharged home today at 12 pm with all medications and paperwork. Medication schedules, therapy recommendations, and any recent labs. Etc. were put in .discharge folder and read over with [patient] . Record review of the residents electronic and paper record in the presence of the DNS on 2/27/2024 failed to reveal a Continuity of Care Discharge/ Transfer of Patient Form which included a recapitulation of the resident's stay, reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescription and over-the-counter), a post-discharge plan of care that is developed with the participation of the resident, with the resident's consent, (the resident representative(s)), which will assist the patient to adjust to his/her new living environment. 3) Record review of Resident ID #9 revealed s/he was admitted to the facility in December of 2023 with diagnoses including but not limited to, anemia and acute kidney failure. Review of a progress note dated 1/4/2024 revealed in part, Resident [discharged ] Home with medications and services All discharge paperwork reviewed and signed with resident. Record review of the residents electronic and paper record in the presence of the DNS on 2/27/2024 failed to reveal a Continuity of Care Discharge/ Transfer of Patient Form which included a recapitulation of the resident's stay, reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescription and over-the-counter), a post-discharge plan of care that is developed with the participation of the resident, with the resident's consent, the resident representative(s), which will assist the patient to adjust to his/her new living environment. During a surveyor interview with the DNS on 2/27/2024 at approximately 12:00 PM she was unable to provide evidence of a Continuity of Care Discharge/Transfer of Patient Form containing a recapitulation of the resident's stay, reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescription and over-the-counter), a post-discharge plan of care for Resident ID #s 6 and 9.

Based on record review and staff interview it has been determined that the facility failed to ensure that residents are free from significant medication errors for 1 of 1 residents reviewed who was administered seizure medications (Keppra, Vimpat, and Phenobarbital) and a blood thinning medication (Lovenox injection) intended for another resident, Resident ID #1. Findings are as follows: Review of the facility policy last revised on 1/1/2022 titled, .General Dose Preparation and Medication Administration, states in part, .Facility staff should comply with Facility policy .and the State Operations Manual when administering medications .Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident .During medication administration, Facility staff should Identify the resident per Facility policy . Record review revealed Resident ID #1 was readmitted to the facility in August of 2023 with diagnoses including, but not limited to, cerebral infarct (stroke), respiratory failure, tracheostomy (surgical opening through the front of the neck into the windpipe for oxygen delivery), bradycardia (low heartrate), hypertensive heart disease (heart problem caused by high blood pressure), gastrostomy (G-tube, tube inserted through the belly that brings nutrition and medication directly to the stomach),and dysphagia (difficulty swallowing). Review of a Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 8 out of 15, indicating moderately impaired cognition. Additional record review revealed progress notes dated 12/21/2023 at 8:26 AM and 9:22 AM, which revealed a change in the resident's condition was reported to the physician. The progress note indicates the resident's family member was notified of a medication error. During surveyor interviews on 12/21/2023 at approximately 11:30 AM and 2:00 PM, with Registered Nurse (RN), Staff A, she indicated that she was the Unit Manager and that she was assigned to work the unit during the 7:00 AM - 3:00 PM shift. She further revealed that she administered Keppra, Vimpat, Phenobarbital, and Lovenox to Resident ID #1 in error. She indicated that after she administered the medications to Resident ID #1, she exited his/her room and realized the medications were not intended for him/her, but for Resident ID #3, who resides in the room next door. She acknowledged that she did not verify Resident ID #1's identity prior to administering him/her Resident ID #3's seizure medications Keppra, Vimpat, Phenobarbital via his/her G-tube and a blood thinning medication, Lovenox injection. During surveyor observations on 12/21/2023 at 11:30 AM and 3:00 PM revealed Resident ID #1 in bed with his/her eyes closed. Record review of the December 2023 Medication Administration Record revealed the following physician's orders with start dates for Resident ID #3, which Resident ID #1 was administered in error on the morning of 12/21/2023. Additionally, review of the U.S. Food and Drug Administration (FDA) online resource for drug labeling revealed the following warnings and precautions of each medication listed. 1. 9/27/2022, Phenobarbital 100 MG, Give 1.5 tablets (total dose 150 MG) via G-tube two times a day for seizures. The drug labeling resource indicates that phenobarbital belongs to a class of drugs known as barbiturates which act on the central nervous system used as a sedative. Additionally, the label indicates that this medication may cause drowsiness, deep coma, hypoventilation (shallow breathing), apnea (temporary cessation of breathing), bradycardia (low heart rate), hypotension (low blood pressure), and syncope (fainting). Furthermore, phenobarbital is contraindicated in patients who have respiratory disease. 2. 10/2/2022, Lovenox injection 120 MG subcutaneously (in the layer under the skin) every 12 hours for left upper extremity deep vein thrombosis (blood clot). The drug labeling resource indicates the most common adverse reactions of Lovenox includes, but are not limited to, bleeding, anemia (low red blood cells), and thrombocytopenia (blood disorder). Additionally, the label indicates certain drug interactions such as aspirin, may increase the risk of hemorrhage [acute blood loss]. 3. 7/13/2023, Keppra Solution 100 MG/milliliters (ML) Give 20 ML (2000 MG) via G-tube every 8 hours for seizure disorder. The drug labeling resource revealed the following in part, .WARNINGS AND PRECAUTIONS .Behavioral abnormalities including psychotic symptoms .irritability, and aggressive behavior .Monitor patients for new or worsening depression .and/or unusual changes in mood or behavior .Most common adverse reactions .Adult patients: somnolence (drowsiness), asthenia (weakness), infection and dizziness . 4. 10/6/2023, Vimpat 200 milligrams (MG), Give 1 tablet via G-tube two times a day for seizures. The drug labeling resource revealed the following in part, .WARNINGS AND PRECAUTIONS .Patients should be advised that VIMPAT may cause dizziness .Caution is advised for patients with known cardiac conduction [how the heart pumps blood] problems .may cause syncope .Multiorgan Hypersensitivity Reactions .Most common adverse reactions .are .headache dizziness, nausea . Additional record review of the December 2023 Medication Administration Record revealed the following scheduled medications Resident ID #1 was administered on the morning of 12/21/2023, after s/he was administered the above-mentioned medications erroneously: - Aspirin 81 MG (medication used for blood thinning in people with a history of stroke) - Doxazosin Mesylate 0.5 MG (medication to treat high blood pressure) - Prevacid 30 MG (medication used to treat acid reflux) Further record review failed to reveal evidence that the pharmacist was contacted to verify the potential medication interactions between Resident ID #1's scheduled medication with the medication s/he was administered in error. Additional record review of a hospital history and physical document dated 11/15/2022 revealed that Resident ID #1 had previously been on Lovenox however it was discontinued because it was causing him/her to have Hemoptysis (when you cough up blood from your lungs). During surveyor interviews with Resident ID #1's Medical Doctor (MD) on 12/22/2023 at 11:08 AM and 12:23 PM, she revealed that she was notified on the morning of 12/21/2023 that Resident ID #1 was administered Keppra, Vimpat, Phenobarbital and Lovenox, medications intended for another resident. She further indicated that she gave orders on 12/21/2023 for nursing to monitor Resident ID #1 for any neurological changes, his/her vital signs to be checked every 4 hours, and blood work (complete blood count, basic metabolic panel, and liver function test). Furthermore, the MD indicated she was notified on 12/22/2023 that the blood work was not obtained on 12/21/2023 and indicated she would have expected to be notified. Additionally, she indicated that the medications Resident ID #1 was administered in error, cause drowsiness and the potential to raise blood pressure. She indicated Keppra takes 48 hours to get out of a person's system. She also indicated Lovenox 120 MG causes a person's blood to be thin for 12 hours. Additionally, she indicated that she would have expected the nurse to have administered the correct medications to the correct resident. During a surveyor interview with the Director of Nursing Services on 12/21/2023 at 12:30 PM, she acknowledged that Resident ID #1 was administered medications intended for Resident ID #3. Additionally, she was unable to provide evidence that Resident ID #1 was kept free from significant medication errors when s/he was administered Keppra, Vimpat, Phenobarbital and Lovenox injection not intended for him/her which had the potential to cause a serious adverse outcome. Furthermore, she indicated that she would have expected the nurse to have administered the correct medications to the correct resident. This facility failure had to the potential to cause more than minimal harm, impairment, or death as Resident ID #1 received Resident ID #3's four significant medications intended for another resident in error.