Every finding on record at Crestwood Nursing & Rehabilitation Center Inc

Based on record review, resident, and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice and the comprehensive person-centered care plan for 1 of 1 resident reviewed on a fluid restriction, Resident ID #17. Findings are as follows: Record review revealed the resident was readmitted to the facility in July of 2023, with diagnoses including, but not limited to, end stage renal disease (a condition in which your kidneys are damaged and lose the ability to filter waste and fluid from the blood properly) and is dependent on renal dialysis. Record review revealed a Quarterly Minimum Data Set assessment dated [DATE] which revealed a Brief Interview for Mental Status score of a 10 out 15, indicating moderately impaired cognition. Record review revealed a dialysis care plan with a start date of 6/12/2024 with an intervention including, but not limited to a fluid restriction of 1,200 milliliters (mL) daily. Record review revealed a physician's order dated 7/7/2023 for a fluid restriction of 1,200 mL daily. Record review of the fluid intake documentation for the months of October and November of 2024 revealed the resident exceeded his/her fluid restriction on the following dates: 10/1/2024 1680 mL 10/3/2024 1500 mL 10/4/2024 1500 mL 10/6/2024 1320 mL 10/7/2024 1260 mL 10/8/2024 1380 mL 10/9/2024 1740 mL 10/12/2024 1560 mL 10/13/2024 1500 mL 10/14/2024 1460 mL 10/15/2024 1500 mL 10/16/2024 1240 mL 10/17/2024 1446 mL 10/18/2024 1620 mL 10/20/2024 1740 mL 10/21/2024 1500 mL 10/22/2024 1260 mL 10/23/2024 1720 mL 10/24/2024 1440 mL 10/26/2024 1740 mL 10/27/2024 1350 mL 10/29/2024 1440 mL 10/30/2024 1740 mL 10/31/2024 1440 mL 11/2/2024 1380 mL 11/3/2024 1260 mL 11/4/2024 1380 mL 11/6/2024 1500 mL 11/7/2024 1970 mL 11/9/2024 1500 mL 11/10/2024 1720 mL 11/11/2024 1320 mL 11/13/2024 1440 mL During a surveyor interview with the resident on 11/14/2024 at 11:45 AM, s/he revealed that s/he drinks what s/he is provided. During a surveyor interview on 11/14/2024 at 12:59 PM with Registered Nurse, Staff A, she acknowledged that the documented fluid intake exceeded 1200 mL daily. Staff A was unable to provide evidence that the fluid restriction was followed as ordered. During a surveyor interview on 11/14/2024 at 1:15 PM with the Director of Nursing Services (DNS), she acknowledged that the documented fluid intake exceeded 1200 mL daily. The DNS was unable to provide evidence that the fluid restriction was followed as ordered.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of practice for 1 of 1 resident's observed for wound care, Resident ID #50. Findings are as follows: According to Lippincott Nursing Procedures, Ninth Edition, page 370, which states in part, .hand hygiene is the single most important procedure in preventing infection .using an alcohol-based hand sanitizer is appropriate for decontaminating the hands .after contact with the patient .non-intact skin, or wound dressings .after removing gloves . Review of the facility policy titled, Clean Dressing Technique, states in part, .Remove old dressing .remove gloves, wash hands (hand sanitizer may be utilized) and apply clean gloves . Record review revealed the resident was admitted to the facility in June of 2023 with diagnoses including, but not limited to, dementia, and a pressure ulcer of the right heel, stage 3 (wound caused by prolonged pressure that penetrates through the layers of the skin and into the fatty tissue). Review of a Wound Evaluation & Management Summary dated 11/14/2024 revealed the resident had a Stage 3 pressure ulcer measuring 1.2 centimeters (cm) by 0.8 cm by 0.1 cm. Record review revealed a physician's order dated 11/8/2024, to cleanse the right heel wound with normal saline, pat dry, apply Medi Honey (ointment) followed by a bordered gauze dressing. During a surveyor observation of the resident's wound treatment on 11/15/2024 at approximately 10:15 AM, Registered Nurse (RN), Staff A, was observed to put on a gown and gloves, remove the resident's soiled dressing, then changed her gloves without performing hand hygiene. Staff A then cleansed the wound, applied the Medi Honey, and then placed the clean dressing onto the wound without changing her gloves or performing hand hygiene. Additionally, Staff A grabbed a marker, wrote on the dressing, and placed the marker in her pocket without changing her gloves or performing hand hygiene. During a surveyor interview on 11/15/2024 at 10:25 AM with Staff A, she indicated that she typically only performs hand hygiene before and after wound care. Staff A acknowledged that she did not perform hand hygiene after removing her gloves and before putting on a clean pair. Additionally, she acknowledged that she did not change her gloves or perform hand hygiene after cleansing the wound and prior to applying the clean dressing. Furthermore, she acknowledged that she did not change her gloves or perform hand hygiene prior to touching the clean marker and had not sanitized the marker prior to putting it in her pocket. During a surveyor interview on 11/15/2024 at 10:51 AM with the Director of Nursing Services, she indicated that she would expect hand hygiene to be performed between glove changes. Additionally, she was unable to explain why the nurse failed to change her gloves and perform hand hygiene prior to applying the clean dressing or touching the marker.

Based on surveyor observations and staff interview, it has been determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, relative to 1 of 3 shower rooms. Findings are as follows: During a surveyor observation on 11/20/2023 at 8:40 AM, in the presence of the Director of Nursing Services (DNS) and the Maintenance Director, of the North Wing shower room, black matter was observed in the grout on the shower stall walls and where the shower wall meets the floor. During a surveyor interview, immediately following the above observation on 11/20/2023, the DNS and Maintenance Director acknowledged the black matter in the grout on the shower stall walls and where the shower wall meets the floor and were in need of cleaning. 43987

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that a resident who is at risk for pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to prevent new ulcers from developing for 1 of 4 resident reviewed who are at risk for developing pressure ulcers, Resident ID #4. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Record review revealed the resident was admitted to the facility in June of 2009 with diagnoses including, but not limited to, persistent vegetative state, contracture of left and right ankle, and obesity. Record review of a Braden Scale (an evaluation for predicting pressure sore risk) dated 9/17/2023 revealed the resident scored a 13, indicating s/he had a moderate risk for developing a pressure sore. Record review of a care plan dated 12/28/2022 revealed a problem of .TBI [Traumatic Brain Injury] Comatose [prolonged state of unconsciousness] .offload bilateral heels as [tolerated]. Record review revealed a physician's order dated 5/31/2022 to offload bilateral heels as tolerated every shift. During surveyor observations on the following dates and times, the resident's heels were not offloaded as ordered and were resting directly on the mattress: -11/15/2023 at 12:00 PM and at 12:20 PM -11/16/2023 at 1:32 PM -11/17/2023 at 11:51 AM -11/20/2023 at 9:10 AM Record review failed to reveal evidence of documentation that the resident was unable to tolerate his/her heels being offloaded on the days of the above-mentioned observations. Record review of the November 2023 Medication Administration Record revealed staff had documented that the residents heels were offloaded as ordered on the above mentioned dates. During a surveyor interview on 11/20/2023 at 9:13 AM with Nursing Assistant, Staff A, she acknowledged that the resident's heels were not offloaded at that time. She further indicated that the resident's heels should be offloaded. During a surveyor interview on 11/20/2023 at 9:18 AM with Registered Nurse, Staff B, she acknowledged that the resident's heels should be offloaded as ordered. During a surveyor interview on 11/20/2023 at 10:57 AM with the Director of Nursing Services, she indicated the order to offload the resident's heels was as tolerated, however she was unable provide evidence that resident's heels were offloaded as ordered or that the resident could not tolerate his/her heels being offloaded.

Based on record review and staff interview it has been determined that the facility failed to ensure that each resident receive adequate supervision based on the resident's assessed needs and risks identified to protect residents from accidents, relative to an incident that occurred between Resident ID #1 and Resident ID #2, resulting in the death of Resident ID #1. Findings are as follows: On [DATE] the Rhode Island Department of Health received a facility reported incident that states in part Just prior to the change in shift, the on-coming RN [Registered Nurse] went to check on the residents in room [room number redacted] ,d+[DATE] [secondary to] door being closed. Abuser [Resident ID #2] was found to be blocking entry into the room however upon gaining access, the RN noted the room looked like bed linens were spread around the room and general disorder. Victim [Resident ID #1] was in the bed but was noted to be motionless and pale. On closer assessment, the RN noted what looked like pillow stuffing inside the mouth of victim and that [s/he] had expired . Record review revealed Resident ID #1 (victim) was admitted to the facility in September of 2021 with diagnoses including, but not limited to Alzheimer's disease, dementia, and Parkinson's disease. Record review of the physician orders revealed that Resident ID #1 was admitted to Hospice services in July of 2022. Record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed s/he was dependent on staff for all aspects of personal care and that his/her cognitive status, mood and behavior was unable to be assessed due to his/her severe cognitive impairment. Record review of Resident ID #1's care plan developed on [DATE] states in part, I am at the end stages of life. Please address my psychosocial needs through contact support to help complete the last days of my life with dignity and grace .provide me with one-to-one visits and offer me redirection and TLC (tender loving care) when I become agitated or anxious .ADL [Activities of Daily Living] Deficit .will maintain a sense of dignity by being clean .safe . Record review for Resident ID #2 (perpetrator) revealed s/he was admitted to the facility on [DATE], after an acute hospital stay following an episode of confusion and paranoid behavior while at home. Further review revealed his/her medical diagnoses include, but not limited to: encephalopathy (a disease in which the brain alters the brain function or structure), delirium (disturbance in mental abilities that results in confused thinking and reduced awareness of surroundings), anxiety disorder, urinary tract infection, and stroke. Record review of Resident ID #2's Admission MDS assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 3 out of 15, indicating severe cognitive impairment. Further review of the MDS revealed the resident was coded as having an acute change in mental status from his/her baseline indicating s/he has fluctuating inattention. Additionally, s/he is coded as feeling down, depressed, or hopeless, having trouble concentrating, having trouble falling asleep and feeling tired or having little energy. Further review of the MDS indicates the resident has behaviors not directed towards others and rejection of care. Record review of Resident ID #2's psycho-social well-being care plan dated [DATE] revealed [Resident] is diagnosed with encephalopathy and delirium and has significant decline in cognitive and functional levels since hospitalization . [Resident] is at risk for decline in psycho-social well-being and mood fluctuations due to personal and significant life events (recent illness and decline in functioning, transition to new environment and PTSD [post-traumatic stress like symptoms] -[resident] is a veteran and did serve in the war). Interventions which state in part, SS [social services] to provide [resident] with support around acclimation to new environment and staff will provide consistency with routines. SS to provide 1:1 visit for support and encourage [resident] to participate in activities and Diversional tasks that are self-soothing and meaningful to [him/her], assess for any triggers or changes in moods/behaviors and report to clinical team .create a calm and nurturing environment to promote a sense of safety and belonging, decrease stimuli in environment as able, psych services as needed for further support . Record review of Resident ID #2's behavioral care plan dated [DATE] revealed the [Resident] is diagnosed with encephalopathy and delirium and has had a significant decline in cognitive and functional levels since his/her hospitalization . [Resident] has been noted to exhibit behaviors of disrobing self, wandering, and pacing the unit and declining care/medications, particularly during times of increased restlessness, confusion, and disorientation. [S/he] requires frequent redirection, cueing and supervision. Interventions which state in part, Staff to address [Resident] by [his/her] name and utilize simple and direct instructions and questions and care. Staff to provide gentle redirection, cueing and explanations of assistance as needed during periods of increased behaviors. Encourage engagement in diversional activities to distract and decrease periods of restlessness and anxiety. Assess for needs and comfort levels and limit distractions and stimuli as able. Psych services as needed for further supports and symptom and med [medication] management. Re-approach at later times during periods of resistance to care . Record review of the emergency room document dated [DATE], revealed the resident was at home with his/her [spouse] on that day. S/he was noted to be very confused and paranoid that people were after him/her and that s/he needed to leave town. Per the [spouses] report, s/he had grabbed a knife and scissors to place in his/her pocket. Additionally, s/he was admitted to an acute care hospital on [DATE] and discharged to the facility on [DATE]. Record review of Resident ID #2's Hospital Neurology Consult document dated [DATE], authored by the neurologist, states in part, .[Resident] who is admitted to medicine for agitation and altered mentation with neurologic exam notable for inattention .it is likely that [resident] is delirious and confused with poor cognitive reserve .At this time, favor delirium and [s/he] may need time to improve given poor cognition reserve. -No further neurologic work up indicated at this time- Would utilize nonpharmacologic interventions to minimize risk of delirium . Additional review of the hospital discharge paperwork indicated the resident needed a follow up appointment with his/her Community Psychiatric Provider. Record review of the resident's follow up appointments revealed the facility had scheduled an appointment for Resident ID #2 for [DATE]. Record review of the facility's provider's admission note for Resident ID #2 revealed a note dated [DATE] which states in part, .delirium-felt multifactorial, including UTI [urinary tract infection] CT [cat scan] brain ok, had some neurocog [neurocognitive] decline prior, check MS [mental status], to be evaluated @ [provider] Seen by neurology @ [hospital]. Need have psych see [resident] here . Record review failed to reveal evidence that Resident ID #2 was seen and evaluated by psychiatric services at the facility as indicated by the provider on [DATE]. Record review of Resident ID #2's nursing progress notes revealed the following: -[DATE] at 2:21 AM s/he was found in another resident's room wrapped in a bed sheet. -[DATE] at 5:23 AM s/he was found standing over roommate, brief removed, donning roommate's shoes. The roommate woke startled. Urine noted on floor. -[DATE] at 5:22 AM .Resident awake at start of shift. Verbal and communicative at times. Amenable to bedrest at 12:00 AM. Slept well for approx. [approximately] 3 hours. Awake at 3 AM, attempting to manipulate roommate's wheelchair and belongings .Requires repetitive step by step cueing. Resident remained awake for approx 2 hours. Required near constant redirection and supervision during that time . -[DATE] at 9:40 AM .Resident OOB [out of bed] and ambulating ad lib this AM, resistive to contact guard assist, physically pulling away from caregiver touch. Stand by assist maintained. Resident attempted exit out of 2 doors in front sitting room, looking for my [spouse]. Resident reassured [his/her spouse] knows where [s/he] is and will be in soon to spend time with [him/her]. Demonstrating STM [short term memory] loss as resident would ambulate again to exits within ,d+[DATE] minutes. 1:1 supervision for approx 45 minutes. Sitting at times with peers, briefly. Entered peers rooms, redirected with good effect. Flat affect, answers simple questions, denied discomfort, refused snacks/beverages. In common area at present for supervision. -[DATE] at 10:00 AM 1:1 supervision was removed as the resident appeared calm and relaxed. Shortly after the alarm sounded and the resident exited the building. Immediate staff response. The resident was initially resistive to returning but ultimately cooperative. 1:1 reinstated and remained in place . -[DATE] at 1:51 AM the resident was seeking exit door. -[DATE] at 4:39 AM .Awake at approx 330 am. Resident found ambulating in room, disrobed. Assisted to bathroom provided. Resident found disrobed ambulating in room attempting to urinate short time after toileting .Refusing bed rest at present .however d/t STM deficit . -[DATE] at 4:47 AM .disrobed with urine on floor. Required frequent redirection. Fidgeting with chux [disposable bed linens for incontinent care] and bed linens .sleeping at approx 2am. -[DATE] at 12:57 PM Resident unaware of [his/her] surroundings. Requesting to have the sheriff called, 'the propane tanks are going to blow up'. Redirection not comprehended. This writer assisted resident to the BR [bathroom] to urinate per resident's request. Upon arrival to the BR resident indicated that the tub was the toilet .Resident then proceeded to take top off of bowl as [s/he] wanted to fix it. 'There is too much water in there, can you hand me my tools' . -[DATE] at 6:24 AM Resident attempted to elope X 2. Redirected by staff. -[DATE] at 6:08 AM Resident voided on roommate's floor mat. Resident found naked and assisted back to bed . -[DATE] at 8:22 AM Resident alert, not present mentally. Roams the facility with no clear intentions. Arbitrarily takes [his/her] pants down to defecate .Needs cueing to eat, redirected several times to sit and eat .Unable to give this resident a shower r/t [related to] mentation .insistent [s/he] needs to see a doctor .repeating [his/her] medical number . -[DATE] at 4:45 AM Resident awake at start of shift. Donning clothing and shoes, saying 'Good morning' to staff and peers. Unable to reorient resident to the time of day. Resident ambulating throughout the unit .Attempted to exit through North wing fire exit .Removed clothing independently X 3 this shift. Urinary void on floor .Resident fell asleep at approx 130am, slept for approx. 3 hours total this shift. Awake at present. Close monitoring for safety. -[DATE] at 9:59 AM Resident with increased anxiousness .refused pills .some confusion still noted .some redirection needed . -[DATE] at 5:25 AM Resident awake at start of shift. Confusion with some delusions noted. Insisting that [s/he] needed to leave to go 'fix' something. Unable to redirect or reorient. Reminded resident to need of stay at facility, resident unable to comprehend .Slept well in bed from approx 1230am until approx 430am. Upon waking, resident removed clothing and incontinent products, urinated on floor. Staff cleaned and redressed, this occurred x 2 more times despite toileting and redirection .resident perseverating on 'gathering up' things. Attempts to redirect and reorient were ineffective . -[DATE] at 6:20 AM .disrobing and urinating on the floor occasionally throughout the shift . -[DATE] at 12:03 AM Resident awake, pulling off clothes wanting to urinate in the corner and breakroom .Acting defensive when asked to please go to bed. Refused to put on pants. Allowing resident to roam as unable to redirect. Close eye placed on resident, tendency to urinate on whom and whatever [s/he] wishes to . -[DATE] at 11:13 AM .Resident eloped. Redirected back into the facility . -[DATE] at 12:38 AM Resident awake shortly after beginning of shift. Difficult to redirect. Took clothes and brief off several times. Needing 1:1 observation. RN providing 1:1 .Continue to observe resident for elopement risk. -[DATE] at 4:01 AM At time of this note resident still awake, ambulating unit. Declines to sit down. Resident states [s/he] will go to bed when everyone else does. This writer explained to resident that all of [his/her] peers are currently. Asked resident again if [s/he] would want to go to bed. Resident agreed. RN walked resident to bed, resident easily distracted by any object in [his/her] room. After about 10 minutes RN able to get resident into bed. -[DATE] at 4:57 AM Resident out of bed within 10 minutes of this writer putting [him/her] to bed .Very manic at this time. Roaming the lower level looking for exits to get out of. Unable to redirect resident .RN needing to provide 1:1 observation for this resident during rounding. Resident constantly taking off clothes . -[DATE] at 11:44 PM Resident having an emotional break. This RN was called to lower level. Found this resident with a metal clock/decoration banking [sic] with another hard object 'FREE THE PEOPLE'. This writer tried to defuse the situation, able to get resident to walk back to [his/her] room. Resident immediately went to roommate banging metal object .FREE THE PEOPLE .Remained in allway [sic] chanting . -[DATE] at 12:14 AM When EMS [emergency medical services] arrived resident still using a hanger beating on a clock. EMT staff and police officer unable to redirect resident to get onto stretcher . -[DATE] 1:46 PM Resident arrived from local hospital at 1:30 PM .instructions from hospital as follows, patient brought to emergency department for episode of delirium was back to baseline by the time [s/he] was assessed by provider .please consider ordering as needed's for agitation for this patient such as Seroquel [antipsychotic medication used to treat mental/mood conditions] . -[DATE] 9:34 PM Resident again urinated on the floor. Redirected to his/her own bed. Resident refused shower and medications. -[DATE] at 5:46 AM Resident sleeping at the start of shift. Resident awake at approximately 12am .removing clothing and bed linens . -[DATE] at 3:20 AM Resident awake for duration of this shift. Agitation, delusions and pacing noted at 12am. Resident voicing concerns of 'ships' 'water' 'helping the people' and 'what would God want you to do?' This writer provided 1:1 supports, frequent reorientation to time and place were briefly effective .Residents behaviors de-escalated after approx. 45 minutes of 1:1 support. Resident took one very brief nap. Awake at present, constant ambulation throughout the hallway, attempting to open office doors. Removing and reorganizing bedding. Resident adamantly refusing bedrest despite voicing being tired and desire to sleep. Stating [resident] wanted Blankets to put on the floor in various locations to sleep 'because I want to'. Insistent despite this writer attempting to redirect resident to bed. Resident becoming politely aggravated with this writers 1:1 supervision .Resident continued asking for blankets, attempting to make 'bed' on wooden gossip bench in common area. Resident agreeable to going in room, but adamantly refusing bedrest because 'I don't want to'. despite continuing to voice being tired. Resident began removing coat hangers from closet and placed them on floor. Attempting to push this writer out of the way when attempting to pick up hangers to avoid tripping. Resident easily redirected. Also pushing this writer when attempting to pick up blankets off of floor that resident laid out. Resident currently in room, making and reorganizing bed linens ambulating to and from room . -[DATE] at 4:35 AM .Donning and doffing clothes repeatedly. Urine noted on the floor near roommates side of room. Resident refusing staff to allow staff to enter the room . -[DATE] at 9:48 PM .staff attempted to change [resident's] brief and [resident] became 'somewhat combative' . -[DATE] at 12:32 AM Upon arrival to shift this writer noted an incident involving resident [ID #2] and [his/her] roommate [Resident ID #1]. 911 and nursing supervisor contacted. Resident [ID #2] removed from facility by [NAME] EMS at 0027am. [NAME] PD [police department] and AG [Attorney General] in house at present. During a surveyor interview at [DATE] at 10:04 AM with Registered Nurse, Staff A, she indicated that on [DATE] she entered the facility to start her shift at approximately 10:00 PM. Upon entering the unit, she initially spoke with the second shift nurse, Licensed Practical Nurse, Staff C. Staff C indicated that earlier that shift, Resident ID #2 was combative during care and had required two staff members for assistance with ADLs. Staff A then revealed that after hearing this report, she went to the room of Resident ID #1 and 2 to check on Resident ID #2. When she got to the room she noticed the door was closed, which was not typical. She was able to peer into the room and was noticed by Resident ID #2, who was standing just inside the room in a t-shirt and brief. As she canvassed the room, she noticed that there were blankets, a hoyer pad and chux pads on Resident ID #2's bed. She asked him/her what was going on, the resident stated to her that she couldn't come in the room. She then looked over to Resident ID #1 who was lying in bed and noticed pillow stuffing on his/her chest, as she attempted to walk into the room, Resident ID #2 closed the door on her stating, You can't come in here, bye. Staff A approached Staff C to inform her that Resident ID #2 was up to something, and Staff A immediately went back to the room. As she tried to open the door, she was met with resistance by Resident ID #2, but she was able to enter the room by pushing the door open. Once in the room, she observed that Resident ID #1's legs were pale and mottled (blotchy, red purplish marbling of the skin) and she observed what she estimated to be two large handfuls of pillow stuffing on Resident ID #1's chest and face. As she approached Resident ID #1, she observed pillow stuffing in his/her mouth. As she proceeded to remove approximately 2 handfuls of the stuffing from Resident ID #1's mouth; Staff A yelled for staff to assist her stating that [Resident ID #2] killed [Resident ID #1]. Staff responded and escorted Resident ID #2 out of the room. Staff A further revealed that Resident ID #2 stated to her, [s/he] tried to kill me first, [s/he] tried to kill me for [AGE] years. Staff A indicated that the Police and EMS responded and EMS pronounced [Resident ID #1] deceased . During a surveyor interview on [DATE] at approximately 10:17 AM with Nursing Assistant, Staff D, she revealed she was assigned to Resident ID #1 and that she provided care to him\her between the hours of 6:00 PM and 7:00 PM. She further revealed that the last time she observed Resident ID #1 alive was just prior to performing rounds at approximately 9:45 PM, further revealing that Resident ID #1 was lying in bed awake and heard making his/her usual grunting sounds. Record review of the police report dated [DATE] for the above-mentioned incident, indicates that Resident ID #2 has been acting in a disorderly manner since s/he arrived at the nursing home 17 days ago. The report also notes that the police responded to this nursing home last week for Resident ID 2's disorderly behavior. The report also reports that before EMS arrived on scene Resident ID #2 mentioned on three occasions that s/he wanted the police to shoot him/her and indicated that s/he had done something very bad tonight. During a surveyor interview on [DATE] at 11:18 AM with Registered Nurse, Staff B, she revealed she was the nurse caring for Resident ID #2 on the evening of [DATE], during which the resident was observed with a hanger banging on a clock shouting Free the People and sent to the hospital for an evaluation. She further indicated that at the time of the episode she called to have the resident transported to an acute care hospital for an evaluation, gave the paperwork to the transport attendants when they arrived and then called the receiving hospital with a verbal report. Additionally, she revealed when she called report to the receiving hospital, she reported to the nurse that the resident was banging on a clock with a hanger, unable to be redirected, that s/he was having a mental break and needed a psych evaluation. During a surveyor interview on [DATE] at 2:15 PM with Resident ID #2's provider at the facility, he indicated that he had ordered the psychiatric evaluation on [DATE] more as a formality and did not order the consult to be done stat as it was not urgent. He further revealed that he would have expected the evaluation to be completed in the next week or 2. Additionally, he acknowledged he had ordered a psychiatric evaluation following an acute episode on [DATE], after the resident returned from a hospital evaluation. The provider further revealed, considering Resident ID #2s most recent hospital evaluation completed, was negative, he would expect that psychiatric services see the resident within a week of the order to further evaluate him/her before starting the resident on any antipsychotic medication. In conclusion, the provider revealed, there was no indication from the resident's behaviors exhibited, that this incident could have been predicted. Record review failed to reveal evidence of a subsequent revision to Resident ID #2's behavioral or psychosocial care plan or any changes were made to the resident's medication regimen were made following the episode on [DATE] when the resident was evaluate at an acute care facility. Additionally, record review failed to reveal evidence that Resident ID #2 was seen and evaluated by psychiatric services after [DATE]. During a surveyor interview on [DATE] at approximately 4:00 PM with the Director of Nursing Services, she acknowledged that there was an incident involving Resident ID #1 and Resident ID #2 that resulted in the death or Resident ID #1.

Based on record review and staff interview it has been determined that the facility failed to protect and keep residents free from physical abuse relative to an incident that occurred between Resident ID #1 and Resident ID #2, resulting in the death of Resident ID #1. Findings are as follows: On [DATE] the Rhode Island Department of Health received a facility reported incident that states in part Just prior to the change in shift, the on-coming RN [Registered Nurse] went to check on the residents in room [room number redacted] ,d+[DATE] [secondary to] door being closed. Abuser [Resident ID #2] was found to be blocking entry into the room however upon gaining access, the RN noted the room looked like bed linens were spread around the room and general disorder. Victim [Resident ID #1] was in the bed but was noted to be motionless and pale. On closer assessment, the RN noted what looked like pillow stuffing inside the mouth of victim and that [s/he] had expired . Record review of the facility policy titled Abuse Prohibition last revised on [DATE] states in part, Policy: It is the policy of this facility to ensure all residents are treated with respect and dignity and that all residents are free from abuse .Definitions .Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm .H. Protection Immediate response to allegations and/or incidents may include as appropriate but not limited to .Increased supervision of the victim and others as needed-rooms changes . Record review revealed Resident ID #1 (victim) was admitted to the facility in September of 2021 with diagnoses including, but not limited to Alzheimer's disease, dementia, and Parkinson's disease. Record review of the physician orders revealed that Resident ID #1 was admitted to Hospice services in July of 2022. Record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed s/he was dependent on staff for all aspects of personal care and that his/her cognitive status, mood and behavior was unable to be assessed due to his/her severe cognitive impairment. Record review of Resident ID #1's care plan developed on [DATE] states in part, I am at the end stages of life. Please address my psychosocial needs through contact support to help complete the last days of my life with dignity and grace .provide me with one-to-one visits and offer me redirection and TLC (tender loving care) when I become agitated or anxious .ADL [Activities of Daily Living] Deficit .will maintain a sense of dignity by being clean .safe . Record review for Resident ID #2 (perpetrator) revealed s/he was admitted to the facility on [DATE], after an acute hospital stay following an episode of confusion and paranoid behavior while at home. Further review revealed his/her medical diagnoses include, but not limited to; encephalopathy (a disease in which the brain alters the brain function or structure), delirium (disturbance in mental abilities that results in confused thinking and reduced awareness of surroundings), anxiety disorder, urinary tract infection, and stroke. Record review of Resident ID #2's Admission MDS assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 3 out of 15, indicating severe cognitive impairment. Further review of the MDS revealed the resident was coded as having an acute change in mental status from his/her baseline indicating s/he has fluctuating inattention. Additionally, s/he is coded as feeling down, depressed, or hopeless, having trouble concentrating, having trouble falling asleep and feeling tired or having little energy. Further review of the MDS indicates the resident has behaviors not directed towards others and rejection of care. Record review of Resident ID #2's psycho-social well-being care plan dated [DATE] revealed [Resident] is diagnosed with encephalopathy and delirium and has significant decline in cognitive and functional levels since hospitalization . [Resident] is at risk for decline in psycho-social well-being and mood fluctuations due to personal and significant life events (recent illness and decline in functioning, transition to new environment and PTSD [post-traumatic stress like symptoms] -[resident] is a veteran and did serve in the war). Interventions which state in part, SS [social services] to provide [resident] with support around acclimation to new environment and staff will provide consistency with routines. SS to provide 1:1 visit for support and encourage [resident] to participate in activities and Diversional tasks that are self-soothing and meaningful to [him/her], assess for any triggers or changes in moods/behaviors and report to clinical team .create a calm and nurturing environment to promote a sense of safety and belonging, decrease stimuli in environment as able, psych services as needed for further support . Record review of Resident ID #2's behavioral care plan dated [DATE] revealed the [Resident] is diagnosed with encephalopathy and delirium and has had a significant decline in cognitive and functional levels since his/her hospitalization . [Resident] has been noted to exhibit behaviors of disrobing self, wandering, and pacing the unit and declining care/medications, particularly during times of increased restlessness, confusion, and disorientation. [S/He] requires frequent redirection, cueing and supervision. Interventions which state in part, Staff to address [Resident] by [his/her] name and utilize simple and direct instructions and questions and care. Staff to provide gentle redirection, cueing and explanations of assistance as needed during periods of increased behaviors. Encourage engagement in diversional activities to distract and decrease periods of restlessness and anxiety. Assess for needs and comfort levels and limit distractions and stimuli as able. Psych services as needed for further supports and symptom and med [medication] management. Re-approach at later times during periods of resistance to care . Record review of the emergency room document dated [DATE], revealed the resident was at home with his/her [spouse] on that day. S/he was noted to be very confused and paranoid that people were after him/her and that s/he needed to leave town. Per the [spouses] report, s/he had grabbed a knife and scissors to place in his/her pocket. Additionally, s/he was admitted to an acute care hospital on [DATE] and discharged to the facility on [DATE]. Additional review of the hospital discharge paperwork indicated the resident needed a follow up appointment with his/her Community Psychiatric Provider. Record review of the resident's follow up appointments revealed the facility had scheduled an appointment for Resident ID #2 for [DATE]. Record review of the facility's provider admission note revealed a note dated [DATE] which states in part, .delirium-felt multifactorial, including UTI [urinary tract infection] CT [cat scan] brain ok, had some neurocog [neurocognitive] decline prior, check MS [mental status], to be evaluated @ [provider] Seen by neurology @ [hospital]. Need have psych see [resident] here . Record review failed to reveal evidence that Resident ID #2 was evaluated by psychiatric services at the facility as indicated by the facility's provider on [DATE]. Record review of Resident ID #2's nursing progress notes revealed the following: -[DATE] at 2:21 AM s/he was found in another resident's room wrapped in a bed sheet. -[DATE] at 5:23 AM s/he was found standing over roommate, brief removed, donning roommate's shoes. The roommate woke startled. Urine noted on floor. -[DATE] at 5:22 AM .Resident awake at start of shift. Verbal and communicative at times. Amenable to bedrest at 12:00 AM. Slept well for approx 3 hours. Awake at 3 AM, attempting to manipulate roommate's wheelchair and belongings .Requires repetitive step by step cueing. Resident remained awake for approx 2 hours. Required near constant redirection and supervision during that time . -[DATE] at 9:40 AM .Resident OOB [out of bed] and ambulating ad lib this AM, resistive to contact guard assist, physically pulling away from caregiver touch. Stand by assist maintained. Resident attempted exit out of 2 doors in front sitting room, looking for my [spouse]. Resident reassured [his/her spouse] knows where [s/he] is and will be in soon to spend time with [him/her]. Demonstrating STM [short term memory] loss as resident would ambulate again to exits within ,d+[DATE] minutes. 1:1 supervision for approx 45 minutes. Sitting at times with peers, briefly. Entered peers rooms, redirected with good effect. Flat affect, answers simple questions, denied discomfort, refused snacks/beverages. In common area at present for supervision. -[DATE] at 10:00 AM 1:1 supervision was removed as the resident appeared calm and relaxed. Shortly after the alarm sounded and the resident exited the building. Immediate staff response. The resident was initially resistive to returning but ultimately cooperative. 1:1 reinstated and remained in place . -[DATE] at 1:51 AM the resident was seeking exit door. -[DATE] at 4:39 AM .Awake at approx 330 am. Resident found ambulating in room, disrobed. Assisted to bathroom provided. Resident found disrobed ambulating in room attempting to urinate short time after toileting .Refusing bed rest at present .however d/t STM deficit . -[DATE] at 4:47 AM .disrobed with urine on floor. Required frequent redirection. Fidgeting with chux [disposable bed linens for incontinent care] and bed linens .sleeping at approx 2am. -[DATE] at 12:57 PM Resident unaware of [his/her] surroundings. Requesting to have the sheriff called, 'the propane tanks are going to blow up'. Redirection not comprehended. This writer assisted resident to the BR [bathroom] to urinate per resident's request. Upon arrival to the BR resident indicated that the tub was the toilet .Resident then proceeded to take top off of bowl as [s/he] wanted to fix it. 'There is too much water in there, can you hand me my tools' . -[DATE] at 6:24 AM Resident attempted to elope X 2. Redirected by staff. -[DATE] at 6:08 AM Resident voided on roommate's floor mat. Resident found naked and assisted back to bed . -[DATE] at 8:22 AM Resident alert, not present mentally. Roams the facility with no clear intentions. Arbitrarily takes [his/her] pants down to defecate .Needs cueing to eat, redirected several times to sit and eat .Unable to give this resident a shower r/t [related to] mentation .insistent [s/he] needs to see a doctor .repeating [his/her] medical number . -[DATE] at 4:45 AM Resident awake at start of shift. Donning clothing and shoes, saying 'Good morning' to staff and peers. Unable to reorient resident to the time of day. Resident ambulating throughout the unit .Attempted to exit through North wing fire exit .Removed clothing independently X 3 this shift. Urinary void on floor .Resident fell asleep at approx 130am, slept for approx. 3 hours total this shift. Awake at present. Close monitoring for safety. -[DATE] at 9:59 AM Resident with increased anxiousness .refused pills .some confusion still noted .some redirection needed . -[DATE] at 5:25 AM Resident awake at start of shift. Confusion with some delusions noted. Insisting that [s/he] needed to leave to go 'fix' something. Unable to redirect or reorient. Reminded resident to need of stay at facility, resident unable to comprehend .Slept well in bed from approx 1230am until approx 430am. Upon waking, resident removed clothing and incontinent products, urinated on floor. Staff cleaned and redressed, this occurred x 2 more times despite toileting and redirection .resident perseverating on 'gathering up' things. Attempts to redirect and reorient were ineffective . -[DATE] at 6:20 AM .disrobing and urinating on the floor occasionally throughout the shift . -[DATE] at 12:03 AM Resident awake, pulling off clothes wanting to urinate in the corner and breakroom .Acting defensive when asked to please go to bed. Refused to put on pants. Allowing resident to roam as unable to redirect. Close eye placed on resident, tendency to urinate on whom and whatever [s/he] wishes to . -[DATE] at 11:13 AM .Resident eloped. Redirected back into the facility . -[DATE] at 12:38 AM Resident awake shortly after beginning of shift. Difficult to redirect. Took clothes and brief off several times. Needing 1:1 observation. RN providing 1:1 .Continue to observe resident for elopement risk. -[DATE] at 4:01 AM At time of this note resident still awake, ambulating unit. Declines to sit down. Resident states [s/he] will go to bed when everyone else does. This writer explained to resident that all of [his/her] peers are currently. Asked resident again if [s/he] would want to go to bed. Resident agreed. RN walked resident to bed, resident easily distracted by any object in [his/her] room. After about 10 minutes RN able to get resident into bed. -[DATE] at 4:57 AM Resident out of bed within 10 minutes of this writer putting [him/her] to bed .Very manic at this time. Roaming the lower level looking for exits to get out of. Unable to redirect resident .RN needing to provide 1:1 observation for this resident during rounding. Resident constantly taking off clothes . -[DATE] at 11:44 PM Resident having an emotional break. This RN was called to lower level. Found this resident with a metal clock/decoration banking [sic] with another hard object 'FREE THE PEOPLE'. This writer tried to defuse the situation, able to get resident to walk back to [his/her] room. Resident immediately went to roommate banging metal object .FREE THE PEOPLE .Remained in allway [sic] chanting . -[DATE] at 12:14 AM When EMS [emergency medical services] arrived resident still using a hanger beating on a clock. EMT staff and police officer unable to redirect resident to get onto stretcher . -[DATE] 1:46 PM Resident arrived from local hospital at 1:30 PM .instructions from hospital as follows, patient brought to emergency department for episode of delirium was back to baseline by the time [s/he] was assessed by provider .please consider ordering as needed's for agitation for this patient such as Seroquel [antipsychotic medication used to treat mental/mood conditions] . -[DATE] 9:34 PM Resident again urinated on the floor. Redirected to his/her own bed. Resident refused shower and medications. -[DATE] at 5:46 AM Resident sleeping at the start of shift. Resident awake at approximately 12am .removing clothing and bed linens . -[DATE] at 3:20 AM Resident awake for duration of this shift. Agitation, delusions and pacing noted at 12am. Resident voicing concerns of 'ships' 'water' 'helping the people' and 'what would God want you to do?' This writer provided 1:1 supports, frequent reorientation to time and place were briefly effective .Residents behaviors de-escalated after approx. 45 minutes of 1:1 support. Resident took one very brief nap. Awake at present, constant ambulation throughout the hallway, attempting to open office doors. Removing and reorganizing bedding. Resident adamantly refusing bedrest despite voicing being tired and desire to sleep. Stating [resident] wanted Blankets to put on the floor in various locations to sleep 'because I want to'. Insistent despite this writer attempting to redirect resident to bed. Resident becoming politely aggravated with this writers 1:1 supervision .Resident continued asking for blankets, attempting to make 'bed' on wooden gossip bench in common area. Resident agreeable to going in room, but adamantly refusing bedrest because 'I don't want to'. despite continuing to voice being tired. Resident began removing coat hangers from closet and placed them on floor. Attempting to push this writer out of the way when attempting to pick up hangers to avoid tripping. Resident easily redirected. Also pushing this writer when attempting to pick up blankets off of floor that resident laid out. Resident currently in room, making and reorganizing bed linens ambulating to and from room . -[DATE] at 4:35 AM .Donning and doffing clothes repeatedly. Urine noted on the floor near roommates side of room. Resident refusing staff to allow staff to enter the room . -[DATE] at 9:48 PM .staff attempted to change [resident's] brief and [resident] became 'somewhat combative' . -[DATE] at 12:32 AM Upon arrival to shift this writer noted an incident involving resident [ID #2] and [his/her] roommate [Resident ID #1]. 911 and nursing supervisor contacted. Resident [ID #2] removed from facility by [NAME] EMS at 0027am. [NAME] PD [police department] and AG [Attorney General] in house at present. Record review failed to reveal evidence of a subsequent revision to Resident ID #2's behavioral or psychosocial care plan or any changes were made to the resident's medication regimen were made following the episode on [DATE] when the resident was evaluate at an acute care facility. Additionally, record review failed to reveal evidence that Resident ID #2 was seen and evaluated by psychiatric services after [DATE]. During a surveyor interview on [DATE] at 10:04 AM with Registered Nurse, Staff A, she indicated that on [DATE] she entered the facility to start her shift at approximately 10:00 PM. Upon entering the unit, she initially spoke with the second shift nurse, Licensed Practical Nurse, Staff C. Staff C indicated that earlier that shift, Resident ID #2 was combative during care and had required two staff members for assistance with ADLs. Staff A then revealed that after hearing this report, she went to the room of Resident ID #1 and 2 to check on Resident ID #2. When she got to the room she noticed the door was closed, which was not typical. She was able to peer into the room and was noticed by Resident ID #2, who was standing just inside the room in a t-shirt and brief. As she canvassed the room, she noticed that there were blankets, a hoyer pad and chux pads on Resident ID #2's bed. She asked him/her what was going on, the resident stated to her that she couldn't come in the room. She then looked over to Resident ID #1 who was lying in bed and noticed pillow stuffing on his/her chest, as she attempted to walk into the room, Resident ID #2 closed the door on her stating, You can't come in here, bye. Staff A approached Staff C to inform her that Resident ID #2 was up to something, and Staff A immediately went back to the room. As she tried to open the door, she was met with resistance by Resident ID # 2, but she was able to enter the room by pushing the door open. Once in the room, she observed that Resident ID #1's legs were pale and mottled (blotchy, red purplish marbling of the skin) and she observed what she estimated to be two large handfuls of pillow stuffing on Resident ID #1's chest and face. As she approached Resident ID #1, she observed pillow stuffing in his/her mouth. As she proceeded to remove approximately 2 handfuls of the stuffing from Resident ID #1's mouth; Staff A yelled for staff to assist her stating that [Resident ID#2] killed [Resident ID #1]. Staff responded and escorted Resident ID #2 out of the room. Staff A further revealed that Resident ID #2 stated to her, [s/he] tried to kill me first, [s/he] tried to kill me for [AGE] years. Staff A indicated that the Police and EMS responded and EMS pronounced [Resident ID #1] deceased . Record review of the police report dated [DATE] for the above-mentioned incident, indicates that Resident ID #2 has been acting in a disorderly manner since s/he arrived at the nursing home 17 days ago. The report also notes that the police responded to this nursing home last week for Resident ID #2's disorderly behavior. The report also states that before EMS arrived on scene Resident ID #2 mentioned on three occasions that s/he wanted the police to shoot him/her and indicated that s/he had done something very bad tonight. During a surveyor interview on [DATE] at approximately 10:17 AM with Nursing Assistant, Staff D, she revealed she was assigned to Resident ID #1 and that she provided care to him\her between the hours of 6:00 PM and 7:00 PM. She further revealed that the last time she observed Resident ID #1 alive was just prior to performing rounds at approximately 9:45 PM, further revealing that Resident ID #1 was lying in bed awake and was heard making his/her usual grunting sounds. During a surveyor interview on [DATE] at 11:18 AM with Registered Nurse, Staff B, she revealed she was the nurse caring for Resident ID #2 on the evening of [DATE], during which the resident was observed with a hanger banging on a clock shouting Free the People. She further indicated that at the time of the episode she called to have the resident transported to an acute care hospital for an evaluation, gave the paperwork to the transport attendants when they arrived and then called the receiving hospital with a verbal report. Additionally, she revealed when she called report to the receiving hospital, she reported to the nurse that the resident was banging on a clock with a hanger, unable to be redirected, that s/he was having a mental break and needed a psych evaluation. During a surveyor interview on [DATE] at approximately 2:50 PM with the Director of Nursing Services, she was unable to provide evidence that Resident ID #1 was kept free from resident to resident abuse. Although Resident ID #2 had been exhibiting behaviors dating back to [DATE]. The facility failed to have this resident evaluated by their psychiatric consultant as indicated in the facility's provider's admission note on [DATE]. Additionally, on [DATE] the facility failed to follow up with the emergency department's recommendations to consider ordering a medication to treat Resident ID #2's agitation.

Based on record review and staff interview it has been determined that the facility failed to address signs of behaviors that the resident was exhibiting such as disrobing self, wandering, pacing the unit and declining care/medications since his/her admission to the facility, as documented in the medical record. Additionally, the facility failed to ensure that each resident receives and is provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, for 1 of 1 resident reviewed, Resident ID #2. Findings are as follows: On [DATE] the Rhode Island Department of Health received a facility reported incident that states in part Just prior to the change in shift, the on-coming RN [Registered Nurse] went to check on the residents in room [room number redacted] ,d+[DATE] [secondary to] door being closed. Abuser [Resident ID #2] was found to be blocking entry into the room however upon gaining access, the RN noted the room looked like bed linens were spread around the room and general disorder. Victim [Resident ID #1] was in the bed but was noted to be motionless and pale. On closer assessment, the RN noted what looked like pillow stuffing inside the mouth of victim and that [s/he] had expired . Record review revealed Resident ID #2 was admitted to the facility on [DATE], after an acute hospital stay following an episode of confusion and paranoid behavior while at home. Resident ID #2 was admitted to the facility with medical diagnoses including, but not limited to: encephalopathy (a disease in which the brain alters the brain function or structure), delirium (disturbance in mental abilities that results in confused thinking and reduced awareness of surroundings) anxiety disorder, urinary tract infection and stroke. Record review of the Hospital Neurology Consult document dated [DATE], authored by the neurologist, states in part, .[Resident] who is admitted to medicine for agitation and altered mentation with neurologic exam notable for inattention .it is likely that [resident] is delirious and confused with poor cognitive reserve .At this time, favor delirium and [s/he] may need time to improve given poor cognition reserve. -No further neurologic work up indicated at this time- Would utilize nonpharmacologic interventions to minimize risk of delirium . Additional review of the hospital discharge paperwork indicated the resident needed a follow up appointment with his/her Community Psychiatric Provider. Record review of the resident's follow up appointments revealed the facility had scheduled an appointment for Resident ID #2 for [DATE]. Record review of Resident ID #2's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 3 out of 15, indicating severe cognitive impairment. Further review of the MDS revealed the resident was coded as having an acute change in mental status from his/her baseline indicating s/he has fluctuating inattention. Additionally, s/he is coded as feeling down, depressed, or hopeless, having trouble concentrating, having trouble falling asleep and feeling tired or having little energy. Further review of the MDS indicates the resident has behaviors not directed towards others and rejection of care. Record review of Resident ID #2's psycho-social well-being care plan dated [DATE] revealed [Resident] is diagnosed with encephalopathy and delirium and has significant decline in cognitive and functional levels since hospitalization . [Resident] is at risk for decline in psycho-social well-being and mood fluctuations due to personal and significant life events (recent illness and decline in functioning, transition to new environment and PTSD [post-traumatic stress like symptoms] -[resident] is a veteran and did serve in the war). Interventions which state in part, SS [social services] to provide [resident] with support around acclimation to new environment and staff will provide consistency with routines. SS to provide 1:1 visit for support and encourage [resident] to participate in activities and Diversional tasks that are self-soothing and meaningful to [him/her], assess for any triggers or changes in moods/behaviors and report to clinical team .create a calm and nurturing environment to promote a sense of safety and belonging, decrease stimuli in environment as able, psych services as needed for further support . Record review of Resident ID #2's behavioral care plan dated [DATE] revealed the [Resident] is diagnosed with encephalopathy and delirium and has had a significant decline in cognitive and functional levels since his/her hospitalization . [Resident] has been noted to exhibit behaviors of disrobing self, wandering, and pacing the unit and declining care/medications, particularly during times of increased restlessness, confusion, and disorientation. [S/he] requires frequent redirection, cueing and supervision. Interventions which state in part, Staff to address [Resident] by [his/her] name and utilize simple and direct instructions and questions and care. Staff to provide gentle redirection, cueing and explanations of assistance as needed during periods of increased behaviors. Encourage engagement in diversional activities to distract and decrease periods of restlessness and anxiety. Assess for needs and comfort levels and limit distractions and stimuli as able. Psych services as needed for further supports and symptom and med [medication] management. Re-approach at later times during periods of resistance to care . Record review of Resident ID #2 nursing progress notes revealed the resident exhibited behaviors on the following dates and times: -[DATE] at 2:21 AM s/he was found in another resident's room wrapped in a bed sheet. -[DATE] at 5:23 AM s/he was found standing over roommate, brief removed, donning roommate's shoes. The roommate woke startled. Urine noted on floor. -[DATE] at 5:22 AM .Resident awake at start of shift. Verbal and communicative at times. Amenable to bedrest at 12:00 AM. Slept well for approx 3 hours. Awake at 3 AM, attempting to manipulate roommate's wheelchair and belongings .Requires repetitive step by step cueing. Resident remained awake for approx 2 hours. Required near constant redirection and supervision during that time . -[DATE] at 9:40 AM .Resident OOB [out of bed] and ambulating ad lib this AM, resistive to contact guard assist, physically pulling away from caregiver touch. Stand by assist maintained. Resident attempted exit out of 2 doors in front sitting room, 'looking for my [spouse]'. Resident reassured [his/her spouse] knows where [s/he] is and will be in soon to spend time with [him/her]. Demonstrating STM [short term memory] loss as resident would ambulate again to exits within ,d+[DATE] minutes. 1:1 supervision for approx 45 minutes. Sitting at times with peers, briefly. Entered peers rooms, redirected with good effect. Flat affect, answers simple questions, denied discomfort, refused snacks/beverages. In common area at present for supervision. -[DATE] at 10:00 AM 1:1 supervision was removed as the resident appeared calm and relaxed. Shortly after the alarm sounded and the resident exited the building. Immediate staff response. The resident was initially resistive to returning but ultimately cooperative. 1:1 reinstated and remained in place . -[DATE] at 1:51 AM the resident was seeking exit door. -[DATE] at 4:39 AM .Awake at approx 330 am. Resident found ambulating in room, disrobed. Assisted to bathroom provided. Resident found disrobed ambulating in room attempting to urinate short time after toileting .Refusing bed rest at present .however d/t [due to] STM deficit . -[DATE] at 4:47 AM .disrobed with urine on floor. Required frequent redirection. Fidgeting with chux [disposable bed linens for incontinent care] and bed linens .sleeping at approx 2am. -[DATE] at 12:57 PM Resident unaware of [his/her] surroundings. Requesting to have the sheriff called, 'the propane tanks are going to blow up'. Redirection not comprehended. This writer assisted resident to the BR [bathroom] to urinate per resident's request. Upon arrival to the BR resident indicated that the tub was the toilet .Resident then proceeded to take top off of bowl as [s/he] wanted to fix it. 'There is too much water in there, can you hand me my tools' . -[DATE] at 6:24 AM Resident attempted to elope X 2. Redirected by staff. -[DATE] at 6:08 AM Resident voided on roommate's floor mat. Resident found naked and assisted back to bed . -[DATE] at 8:22 AM Resident alert, not present mentally. Roams the facility with no clear intentions. Arbitrarily takes [his/her] pants down to defecate .Needs cueing to eat, redirected several times to sit and eat .Unable to give this resident a shower r/t [related to] mentation .insistent [s/he] needs to see a doctor .repeating [his/her] medical number . -[DATE] at 4:45 AM Resident awake at start of shift. Donning clothing and shoes, saying 'Good morning' to staff and peers. Unable to reorient resident to the time of day. Resident ambulating throughout the unit .Attempted to exit through North wing fire exit .Removed clothing independently X 3 this shift. Urinary void on floor .Resident fell asleep at approx 130am, slept for approx. 3 hours total this shift. Awake at present. Close monitoring for safety. -[DATE] at 9:59 AM Resident with increased anxiousness .refused pills .some confusion still noted .some redirection needed . -[DATE] at 5:25 AM Resident awake at start of shift. Confusion with some delusions noted. Insisting that [s/he] needed to leave to go 'fix' something. Unable to redirect or reorient. Reminded resident to need of stay at facility, resident unable to comprehend .Slept well in bed from approx 1230am until approx 430am. Upon waking, resident removed clothing and incontinent products, urinated on floor. Staff cleaned and redressed, this occurred x 2 more times despite toileting and redirection .resident perseverating on 'gathering up' things. Attempts to redirect and reorient were ineffective . -[DATE] at 6:20 AM .disrobing and urinating on the floor occasionally throughout the shift . -[DATE] at 12:03 AM Resident awake, pulling off clothes wanting to urinate in the corner and breakroom .Acting defensive when asked to please go to bed. Refused to put on pants. Allowing resident to roam as unable to redirect. Close eye placed on resident, tendency to urinate on whom and whatever [s/he] wishes to . -[DATE] at 11:13 AM .Resident eloped. Redirected back into the facility . -[DATE] at 12:38 AM Resident awake shortly after beginning of shift. Difficult to redirect. Took clothes and brief off several times. Needing 1:1 observation. RN providing 1:1 .Continue to observe resident for elopement risk. -[DATE] at 4:01 AM At time of this note resident still awake, ambulating unit. Declines to sit down. Resident states [s/he] will go to bed when everyone else does. This writer explained to resident that all of [his/her] peers are currently. Asked resident again if [s/he] would want to go to bed. Resident agreed. RN walked resident to bed, resident easily distracted by any object in [his/her] room. After about 10 minutes RN able to get resident into bed. -[DATE] at 4:57 AM Resident out of bed within 10 minutes of this writer putting [him/her] to bed .Very manic at this time. Roaming the lower level looking for exits to get out of. Unable to redirect resident .RN needing to provide 1:1 observation for this resident during rounding. Resident constantly taking off clothes . -[DATE] at 11:44 PM Resident having an emotional break. This RN was called to lower level. Found this resident with a metal clock/decoration banking [sic] with another hard object 'FREE THE PEOPLE'. This writer tried to defuse the situation, able to get resident to walk back to [his/her] room. Resident immediately went to roommate banging metal object .FREE THE PEOPLE .Remained in allway [sic] chanting . -[DATE] at 12:14 AM When EMS [emergency medical services] arrived resident still using a hanger beating on a clock. EMT staff and police officer unable to redirect resident to get onto stretcher . -[DATE] 1:46 PM Resident arrived from local hospital at 1:30 PM .instructions from hospital as follows, patient brought to emergency department for episode of delirium .recommendations for next line providers at SNF [skilled nursing facility] please consider ordering as needed's for agitation for this patient such as Seroquel [antipsychotic medication used to treat mental/mood conditions] . -[DATE] 9:34 PM Resident again urinated on the floor. Redirected to his/her own bed. Resident refused shower and medications. -[DATE] at 5:46 AM Resident sleeping at the start of shift. Resident awake at approximately 12am .removing clothing and bed linens . -[DATE] at 3:20 AM Resident awake for duration of this shift. Agitation, delusions and pacing noted at 12am. Resident voicing concerns of 'ships' 'water' 'helping the people' and 'what would God want you to do?' This writer provided 1:1 supports, frequent reorientation to time and place were briefly effective .Residents behaviors de-escalated after approx. 45 minutes of 1:1 support. Resident took one very brief nap. Awake at present, constant ambulation throughout the hallway, attempting to open office doors. Removing and reorganizing bedding. Resident adamantly refusing bedrest despite voicing being tired and desire to sleep. Stating [resident] wanted Blankets to put on the floor in various locations to sleep 'because I want to'. Insistent despite this writer attempting to redirect resident to bed. Resident becoming politely aggravated with this writers 1:1 supervision .Resident continued asking for blankets, attempting to make 'bed' on wooden gossip bench in common area. Resident agreeable to going in room, but adamantly refusing bedrest because 'I don't want to'. despite continuing to voice being tired. Resident began removing coat hangers from closet and placed them on floor. Attempting to push this writer out of the way when attempting to pick up hangers to avoid tripping. Resident easily redirected. Also pushing this writer when attempting to pick up blankets off of floor that resident laid out. Resident currently in room, making and reorganizing bed linens ambulating to and from room . -[DATE] at 4:35 AM .Donning and doffing clothes repeatedly. Urine noted on the floor near roommates side of room. Resident refusing staff to allow staff to enter the room . -[DATE] at 9:48 PM .staff attempted to change [resident's] brief and [resident] became 'somewhat combative' . Record review of the facility's provider's admission note revealed a note dated [DATE] which states in part, .delirium-felt multifactorial, including UTI [urinary tract infection] CT [cat scan] brain ok, had some neurocog [neurocognitive] decline prior, check MS [mental status], to be evaluated @ [provider] Seen by neurology @ [hospital]. Need have psych see [resident] here . Additional record review failed to reveal evidence that Resident ID #2 was seen and evaluated by their consultant psychiatric services as indicated by the provider on [DATE]. Record review of the hospital After Visit Summary dated [DATE] states in part, Patient was brought to the emergency department for episode of delirium, was back to baseline .Altered Mental Status work-up was negative. Next line providers at SNF Please consider ordering as needed's for agitation for this patient such as Seroquel. Record review failed to reveal evidence of a subsequent revision to Resident ID #2's behavioral or psychosocial care plan or any changes were made to the resident's medication regimen were made following the episode on [DATE] when the resident was evaluate at an acute care facility. Additionally, record review failed to reveal evidence that Resident ID #2 was seen and evaluated by psychiatric services after [DATE]. During a surveyor interview on [DATE] at 11:18 AM with Registered Nurse, Saff B, she revealed she was the nurse caring for Resident ID #2 on the evening of [DATE], during which the resident was observed with a hanger banging on a clock shouting Free the People. She further indicated that at the time of the episode she called to have the resident transported to an acute care hospital for an evaluation, gave the paperwork to the transport attendants when they arrived and then called the receiving hospital with a verbal report. Additionally, she revealed when she called report to the receiving hospital, she reported to the nurse that the resident was banging on a clock with a hanger, unable to be redirected, that s/he was having a mental break and needed a psych evaluation. During a surveyor telephone interview on [DATE] at 12:53 PM with the facility's provider that was overseeing the resident's care at the facility, he revealed that he was aware that the resident was transferred to an acute care facility for an evaluation following an acute episode on [DATE]. Additionally, the provider acknowledged that the acute care facility made recommendations to consider ordering PRN (as needed) medications and he further revealed that he wanted psychiatric services to evaluate the resident prior to adding a PRN medication to address his/her agitation. During a surveyor interview on [DATE] at 1:05 PM with Registered Nurse (RN), Staff E, she revealed that RN, Staff F had contacted the facility's psychiatric services via email on [DATE] after the resident returned to the facility. Review of the email sent to the consultant psychiatric Advanced Practice Registered Nurse (APRN) by Staff F, dated [DATE] at 3:19 PM, revealed a request was made to the APRN to have the resident seen soon, due to an acute episode of a question of delirium and symptoms almost PTSD like. Further revealing that after the previous night's episode, the resident was sent to the emergency room and that s/he had returned at baseline. Additionally, the email revealed that the resident's provider at the facility had requested a psychiatric consult. During a surveyor interview with Staff F, on [DATE] at 9:21 AM, she revealed the facility provider had ordered for the psychiatric evaluation following the resident's hospital evaluation on [DATE]. Additionally, she revealed that she sent the email to the consultant psychiatric APRN on [DATE] and would have followed up with her on Friday if Resident ID #2 had not been seen yet. During a surveyor interview on [DATE] at 12:05 PM with the consultant psychiatric APRN, she revealed that she had not received the email from the facility and could not explain why. She further revealed that if she had received the email, she would have responded to them that day. Additionally, she indicated that if it was urgent, the facility could call her, and she or a colleague would have come to see the resident that day. Lastly, the APRN revealed delirium can wax and wane and can be prolonged and would want to treat any underlying problem and then prescribe an antipsychotic medication. Record review revealed that Resident ID #1 was admitted to the facility in September of 2021 with diagnoses including, but not limited to Alzheimer's disease, dementia, and Parkinson's disease and s/he was admitted to Hospice services in July of 2022. Additional record review for Resident ID #1 revealed a quarterly MDS dated [DATE] which indicated s/he was dependent on staff for all aspects of care and that his/her cognitive status, mood and behavior was unable to be assessed due to (his/her) severe cognitive impairment. Record review of Resident ID #1's care plan developed on [DATE] states in part, I am at the end stages of life. Please address my psychosocial needs through contact support to help complete the last days of my life with dignity and grace .provide me with one-to-one visits and offer me redirection and TLC (tender loving care) when I become agitated or anxious .Further review of the care plan for ADL (Activities of Daily Living) Deficit .will maintain a sense of dignity by being clean .safe . Additional record review of Resident ID #2's progress notes revealed a progress note dated [DATE] at 12:32 AM, authored by Registered Nurse, Staff A that states in part, Upon arrival to shift this writer noted an incident involving resident [ID #2] and [his/her] roommate [Resident ID #1]. 911 and nursing supervisor contacted. Resident [ID #2] removed from facility by [NAME] EMS at 0027am. [NAME] PD [police department] and AG [Attorney General] in house at present. During a surveyor interview on [DATE] at 10:04 AM with Staff A, she indicated that on [DATE] she entered the facility to start her shift at approximately 10:00 PM. Upon entering the unit, she initially spoke with the second shift nurse, Licensed Practical Nurse, Staff C. Staff C indicated that earlier that shift, Resident ID #2 was combative during care and had required two staff members for assistance with ADLs. Staff A then revealed that after hearing this report, she went to the room of Resident ID #1 and 2 to check on Resident ID #2. When she got to the room she noticed the door was closed, which was not typical. She was able to peer into the room and was noticed by Resident ID #2, who was standing just inside the room in a t-shirt and brief. As she canvassed the room, she noticed that there were blankets, a hoyer pad and chux pads on Resident ID #2's bed. She asked him/her what was going on, the resident stated to her that she couldn't come in the room. She then looked over to Resident ID #1 who was lying in bed and noticed pillow stuffing on (his/her) chest, as she attempted to walk into the room, Resident ID #2 closed the door on her stating, You can't come in here, bye. Staff A approached Staff C to inform her that Resident ID #2 was up to something, and Staff A immediately went back to the room. As she tried to open the door, she was met with resistance by Resident ID #2, but she was able to enter the room by pushing the door open. Once in the room, she observed that Resident ID #1's legs were pale and mottled (blotchy, red purplish marbling of the skin) and she observed what she estimated to be two large handfuls of pillow stuffing on Resident ID #1's chest and face. As she approached Resident ID #1, she observed pillow stuffing in his/her mouth. As she proceeded to remove approximately 2 handfuls of the stuffing from Resident ID #1's mouth; Staff A yelled for staff to assist her stating that [Resident ID #2] killed [Resident ID #1]. Staff responded and escorted Resident ID #2 out of the room. Staff A further revealed that Resident ID #2 stated to her, [s/he] tried to kill me first, [s/he] tried to kill me for [AGE] years. Staff A indicated that the Police and EMS responded, and EMS pronounced [Resident ID #1] deceased . During a subsequent interview on [DATE] at 2:15 PM with Resident ID #2's provider at the facility, he indicated that he had ordered the psychiatric evaluation on [DATE] more as a formality and did not order the consult to be done stat as it was not urgent. He further revealed that he would have expected the evaluation to be completed in the next week or 2. Additionally, he acknowledged he had ordered an additional psychiatric evaluation following an acute episode on [DATE], after the resident returned from a hospital evaluation. The provider further revealed, considering Resident ID #2's most recent hospital evaluation completed on [DATE], was negative, he would expect that psychiatric services see the resident within a week of the order to further evaluate him/her before starting the resident on any antipsychotic medication. In conclusion, the provider revealed, there was no indication from the resident's behaviors exhibited, that this incident could have been predicted. During a surveyor interview with the Director of Nursing Services on [DATE] at approximately 2:50 PM, she revealed that Resident ID #2 had a follow up appointment with psychiatric services scheduled on [DATE] and that the facility psychiatric consultant was emailed on [DATE] to see the resident. Additionally, she was unable to provide evidence that Resident ID #2 was seen by psychiatric services as ordered to assist in maintaining his/her highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Refer to related citations F600 and F689

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 2 of 3 residents reviewed for respiratory care, Resident ID #s 1 and 2. Findings are as follows: According to Brunner and Sudarth's textbook, Medical and Surgical Nursing, 7th Edition, 1992, p. 524, as with other medications, oxygen is administered with care, and its effects on each patient are carefully assessed. Oxygen is a drug and except in emergency situations is prescribed by a physician. Review of the facility policy titled Oxygen Administration states in part, Check the physician's order for liter flow and method of administration .Documentation: 1. Ensure that a physician's order has been obtained. 2. Document the date, time, amount and method of the oxygen administration. 3. Document the resident's condition before and after the initiation of therapy. 4. Ensure that there is evidence of oxygen administration for the duration of the therapy. 1. Review of the record for Resident ID #1 revealed s/he was admitted to the facility in April of 2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident ID #1's physician's orders failed to reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a document titled Vitals Report revealed oxygen was administered for Resident ID #1 at 3 Liters(L) on the following dates and times: -9/13/2021 at 12:08 AM -9/12/2021 at 5:41 PM, 10:29 AM and 12:45 AM -9/11/2021 at 8:00 PM and 1:48 PM Further review of Resident ID #1's clinical record revealed the following progress notes: -9/09/2021 at 1:51 AM . SpO2 [percentage of oxygen in someone's blood] was at 70% on room air while lying in bed. HOB [head of bed] elevated and O2 [oxygen] applied via nasal cannula at 2L[Liters] and rechecked with SpO2 at 89-90% -09/04/2021 . Resident awake most of the night .uncomfortable. sp02 88% on RA[room air]-02 2L NC[nasal cannula: a device used to deliver oxygen] applied. -8/31/2021 at 6:12 AM, Resident slept well-remains in O2 2L-pox 99% . -8/30/2021 at 5:14 PM, .02 sat 82% on r/a . During an interview with Registered Nurse (RN) Supervisor, Staff A on 9/16/2021 at 11:37AM, she revealed that Resident ID #1 has been using oxygen as needed. Additionally, she indicated that on 9/13/2021 the resident was using the oxygen continuously and that she had increased it to from 3L to 4L. Staff A could not provide evidence that there was an order in place for oxygen. 2. Review of the clinical record for Resident ID #2 revealed s/he was admitted to the facility in July of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident ID #2's physician's orders failed to reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a facility document titled Vitals Report revealed oxygen was administered to Resident ID #2 at 2 L on the following dates and times: -8/30/2021 at 9:02 PM -8/26/2021 at 11:50 AM -8/25/2021 at 6:52 PM -8/24/2021 at 3:38 PM and 8:51 AM -8/23/2021 at 8:12 PM -8/22/2021 at 9:05 PM and 10:56 AM -8/21/2021 at 5:22 PM and 9:27 AM -8/20/2021 at 5:58 PM and 4:21 AM -8/19/2021 at 5:23 PM, 10:25 AM and 9:57AM -8/18/2021 at 4:07 PM, 12:18 PM and 6:34 AM -8/17/2021 at 3:57 PM, 11:23 AM and 2:11 AM -8/16/2021 at 2:06 PM, 10:29 AM and 12:54 AM During a surveyor interview on 9/16/2021 at 1:00 PM with RN Supervisor, Staff A, she revealed that Resident ID #2 has been using oxygen as needed since his/her admission. Additionally, she indicates that the resident uses the concentrator while in his/her room and the portable cylinder to ambulate throughout the facility. Staff A was not able to provide evidence that there was an oxygen order for this resident. During an interview with the Director of Nursing Services on 9/16/2021 at 2:41 PM, she acknowledged that Resident IDs #1 and 2 has been receiving oxygen at the facility.

Based on record review and staff interview, it has been determined the facility failed to ensure a resident's drug regimen is free from unnecessary [CONDITION(S)] drugs related to as needed anti-anxiety drugs extended beyond 14 days without an end date by the prescribing practitioner for 1 of 4 sample residents reviewed for unnecessary medications, Resident ID #18. Findings are as follows: Record review for the resident revealed a physician's order dated 4/14/2021 for Lorazepam (anti-anxiety drug) 2 mg (milligram)/ml (milliliter) administer 0.25 ml/0.5 mg as needed for restlessness every 4 hours. Record review failed to reveal an end date for this medication. Record review of the consultant pharmacist document titled Consultation Report dated 6/2/2021 revealed the following, REPEATED RECOMMENDATION from 5/16/2021 .PRN[as needed] order for an anxiolytic [Lorazepam], which has been in place for greater than 14 days without a stop date . Record review of the Medication Administration Record from 4/14/2021 through 6/16/2021 revealed that the resident received the above medication on 5/13, 5/23, 5/28, 5/31, 6/10 and 6/14/2021 (6 times beyond the initial 14 days allowed). During a surveyor interview on 6/17/2021 at 11:55 AM, the Director of Nursing Services could not provide evidence of a stop date for the above medication.

Based on observations, interviews, record reviews, and policy reviews the facility failed to follow their Infection Control Policies and the Center for Disease Control and Prevention (CDC) guidance when the facility failed to ensure staff screening forms were completed upon entry, failed to keep clean linen carts covered for 3 out of the 4 small clean linen carts, staff failed to utilized Personal Protective Equipment (PPE) according to professional standards, and staff failed to perform proper hand hygiene in the kitchen potentially affecting multiple units and residents in the facility. Findings: 1. The Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee (HICPAC) and CDC publication titled Guidelines for Environmental Infection Control in Health-Care Facilities updated in July, 2019 states in part .Functional packaging of laundry can be achieved in several ways, including .placing clean linen in a properly cleaned cart and covering the cart with disposable material or a properly cleaned reusable textile material that can be secured to the cart . Review of facility policy titled Laundry Guidelines states all clean linen will be stored covered. On 11/25/2020 at 11:05 a.m., two upper level units (West and North) were noted to have 2 out of 3 uncovered stocked small linen carts. The West unit had their clean linen cart in the hallway left open and uncovered exposing all linen for about 5 minutes. No staff were noted near clean linen cart. The North unit had their clean linen cart in the hallway left open and uncovered exposing all linen for about 5 minutes. Interview with RN#2 during the 11:05 a.m. observation revealed that she expects the small clean linen carts to be covered at all times and that each unit on the upper level has one and was not sure why the clean linen cart was not covered. Observation on 11/25/2020 at 1:25 p.m. on the upper level North unit noted an uncovered small linen cart for about 5 minutes. No staff were present around the vicinity of the cart at this time. Observation on 11/25/2020 at 3:45 p.m. on the upper level units noted that all three units had their small clean linen carts open and uncovered exposing all linen. Interview with Recreation staff #1 at 3:53 p.m. revealed that she expects all small clean linen carts on the units to be covered at all times. Recreation staff #1 then went to the closest clean linen cart to her (West unit) and covered the linen. Interview with DNS at 3:35 p.m. confirmed that all 4 small clean linen carts in hallways should be covered at all times and that it is her expectation that staff cover them on all the units. 2. During the kitchen observation at about 11:15 a.m. on 11/25/2020, dietary aide #1 went to hand washing station and placed right hand under running water for 8 seconds and then used left hand to apply soap and rubbed hands together for 4 seconds. Dietary aide #1 then rinsed hands under running water and towel dried hands using clean paper towel. Interview on 11/25/2020 at 11:16 a.m. revealed that dietary aide #1 had received training on proper hand hygiene and she/he knew that she/he should rub hands together with soap including lathering back of hands, between fingers, and underneath nails and then scrub hands for at least 20 seconds. Dietary aide #1 verbalized he usually does it for 20 seconds. Interview with DNS at about 3:30 p.m. revealed that it is her expectation that dietary staff should perform hand hygiene properly by washing both hands with soap and water for at least 20 seconds as needed throughout day. 3. The Center for Disease Control and Prevention (CDC) publication titled Using Personal Protective Equipment (PPE) , updated on 08/19/2020, states in part, .Respirator straps should be placed on crown of head (top strap) and base of neck (bottom strap). Perform a user seal check each time you put on the respirator . Review of Manual for Kimtech N95 Pouch Respirator model number indicates in step 7 of 10 that bottom strap should be placed on base of neck and step 8 of 10 indicates top strap should be placed on crown of head (top strap) for a proper protection and comfort. During an observation at 10:45 a.m. on 11/25/2020, the Administrator and RN #1 were observed near the DNS' office on the lower level with both straps of their N95 mask together at the middle of the back of head place directly on ears. During observations at about 1:30 p.m. on 11/25/2020 on the lower level hallway near break room Admissions clerk was observed with both strap above ear level and placed in the middle of the back of head and Human Resources clerk was observed with both straps below ears placed at base of neck. Human resources clerk and Admissions clerk are cross-trained and at times work as certified nursing assistants (CNA). During kitchen observations at about 11:15 a.m. on 11/25/2020, Supervisor Food Services observed with both straps at ear level and placed in the middle of back of head and dietary aide #1 observed with top strap over visor/bill of baseball cap and bottom strap at base of head. All N95 staff observations mentioned were noted to be using the same N95 mask model number . Interview with RN#1, Admissions clerk, Human Resource clerk, and dietary aides #1 and Supervisor Food Services confirmed they had received training regarding donning their N95 respirator and face masks. RN #1 confirmed N95 straps should be placed at the crown of head and base of neck. Interview with Nursing Supervisor at 1:53 p.m. reveal that he/she expects all staff in the facility to correctly wear an N95 mask. He/she also stated that training has been provided to all staff this year including in-service by the National Guard. He/she verbalized that he/she conducts the in-service themselves, but did not instruct staff about correct N95 strap placement and training was not provided for each individual respirator type used in the facility. He/she verbalized he/she is not sure if the DNS has trained staff regarding N95 strap placement. Interview with DNS at about 3:38 p.m. on 11/25/2020 revealed that it is her expectation that all facility staff wear their N95 straps correctly as recommended including dietary personnel. 4. The CDC publication titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated on 11/04/2020, states in part .Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection and that they are [MEDICATION NAME] source control . Facility policy review titled COVID-19: General Screening and Health Care Personnel (HCP)/Visitor Response states Screening of all staff and any visitors is done upon entrance into the facility and The screening includes symptom screening questions a d quarantine screening questions; both sections must be completed with each and every person entering the facility. There are no exceptions. Record review of forms titled COVID-19 screening tool from 10/23/2020 through 11/8/ revealed the following: Staff A entered the facility without completing the screening tool questions relative to risk factors including close contacts, recent travel, and quarantine or isolation status. No date on screening tool noted. Staff B entered the facility without completing any of the screening tool questions relative to symptomology and risk factors including close contacts, recent travel, and quarantine or isolation status. Screening tool dated 10/23/2020. X-ray technician entered the facility without completing any of the screening tool questions relative to symptomology and risk factors including close contacts, recent travel, and quarantine or isolation status. Screening tool dated 10/24/2020. CNA#1, entered the facility without completing any of the screening tool questions relative to symptomology and risk factors including close contacts, recent travel, and quarantine or isolation status. Screening tool dated 11/8/2020. During an interview on 11/23/2020 at about 3:10 p.m., the DNS indicated staff or anyone entering the facility is to be screened using the questionnaire and completing questionnaire prior to being cleared to enter the facility. He/she verbalized all questions on the screening tool should be answered. He/she indicated the facility staff member conducting the screening is responsible for completion of form and indicating if the person is allowed entry into facility or not.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide a sanitary environment to help prevent the development and transmission of infections for 1 out of 3 residents observed on contact precautions (ID # 167) and 2 out of 2 residents observed during insulin administration (ID# 18 and 54). Findings are as follows: 1) Record review for Resident ID # 167 revealed s/he was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. S/he had an active order for a [MEDICATION NAME], an antibiotic used to treat [MEDICAL CONDITION], through 2/7/19. Surveyor observation of the resident's room on 2/7/19 at 9:38 AM, revealed a sign posted outside the door which stated, STOP please see nursing before entering. CNA, staff A, was observed in the room tying up and removing the used bag from the commode, which contained body waste, without the use of gloves. The CNA was further observed putting dirty laundry into a plastic bag and tying it, also without using gloves. Standard precautions require the use of gloves when handlng equipmennt that is likely contaminated with infectious body fluid. During surveyor interview with CNA, staff A, on 2/7/19 at 9:42 AM she acknowledged that she should have worn gloves while tying the bag from the commode and bagging the dirty laundry. During surveyor interview with the Director of Nursing Services (DNS) on 2/7/19 at 12:53 PM, she revealed that the resident was on [MEDICAL CONDITION] precautions. She further acknowledged that the CNA should have worn gloves while handling dirty laundry and tying the bag from the commode. 2) Record review of Resident ID #18 revealed a current physician's orders [REDACTED]. Surveyor observation of Nurse, Staff B, on 2/6/19 at 12:07 PM revealed the nurse putting on gloves, proceeding to draw up the insulin, touch the medication cart, close the door of the medication room and walk down the hallway to the resident's room. While in the room she gave the his/her oral medication, moved the over bed table, blankets and administered the insulin. The nurse did not perform hand hygiene or change gloves prior to the administration of the insulin. 3) Record review of Resident ID # 54 revealed a current physician's orders [REDACTED]. Surveyor observation of Nurse, Staff B, on 2/6/19 at 12:19 PM revealed the nurse putting on gloves, proceeding to draw up the insulin, touch the medication cart, close the door of the medication room and walk down the hallway to the resident's room. While in the room she moved the resident's over bed table, blankets and administered the insulin. The nurse did not perform hand hygiene or change gloves prior to administration of the insulin. During surveyor interview with Nurse, Staff B, on 2/6/19 at 12:25 PM she acknowledged that she should have washed her hands and changed her gloves prior to the insulin administration.

Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident's drug regimen is free from duplicate therapy for 1 of 15 sample residents, ID # 7. Findings are as follows: Record review of resident ID # 7 revealed physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. The facility failed to ensure that this resident's drug regimen was free from medications that substantially duplicate the effects of another medication the resident is taking. A nurse who administered the PRN medications was interviewed on 1/16/15 at 3:00 PM and was unable to give a clinical reason as to why she chooses one medication rather than the other to treat the resident's anxiety. The primary care physician, when questioned by the surveyor about the two medications on 1/20/15, was unable to explain why both medications were needed and subsequently discontinued the [MEDICATION NAME].

Based on record review it has been determined that the facility failed to ensure that medication irregularities are identified by the pharmacist during monthly medication review for 1 of 15 sample residents (ID # 7). Findings are as follows: Record review of resident ID # 7 revealed orders dated 11/1/15 to administer trazodone and lorazepam as needed for anxiety. Review of the resident's Medication Administration Records for December 2014 and January 2015 revealed that both the trazodone and lorazepam were administered for anxiety. Review of the monthly pharmacy's Medication Regimen Review for December 2014 and January 2015 revealed the pharmacist failed to identify or report the duplicate medication therapy. When interviewed on 1/20/2015 at 11:30 AM, the Director of Nurses was unable to produce evidence that the pharmacist had identified the irregularity. Refer to F 329. "You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with applicable provisions of the 'Rules and Regulations for Licensing of Nursing Facilities' they are deficiencies under State Regulations and grounds for licensure sanctions."

Based on surveyor observation, it was determined that the facility has failed to provide housekeeping services to maintain a sanitary environment in two of two medication rooms. Findings are as follows: During inspection of the upper level medication room on 1/16/15 at approximately 10:15 AM, an emergency cart stored in the room was observed to have a heavy accumulation of dust and grit. The shelves of the metal cart had an accumulation of dust and dirt, and items stored on the cart for emergency use were also dirty. Supplies included: - A red plastic backboard on the bottom shelf of the cart which had small dust balls clinging to it when it was lifted from the cart. - A suction machine that was covered with dust. - A box labeled "Manual Resuscitator," (i.e. the ambu bag), which was covered with dust and grit. Inspection of the lower level emergency cart revealed it to be in similar condition. The lower level medication room also had a below the shelf cabinet which had very dirty/dusty/gritty shelves. Stored on the shelves were supplies such as denture cups, toothbrushes (in plastic), toothpaste, shower caps, wash basins and urinals. A drawer containing medication cups had a heavy accumulation of dust. Another drawer containing 2 partial boxes of scalpels had an accumulation of dust. When interviewed on 1/16/2015 at approximately 1:00 PM, the Director of Nurses told the surveyor that there is no cleaning schedule for these rooms.

Based on record review and staff interviews, it was determined the facility has failed to ensure that services provided by the facility meet professional standards of quality for 1 of 1 relevant sample residents (ID# 10) relative to Physicians orders for a [DEVICE]. Findings are as follows: The State of Rhode Island Rules and Regulations for the Licensing of Nurses and Standards for the Approval of Basic Nursing Education Programs (R5-34-NUR/ED), Section 1.31, defines "Nursing", and states, in part: "It provides care and support of individuals and families during periods of wellness, illness, and injury and incorporates the appropriate medical plan of care as prescribed by a duly licensed physician, dentist, podiatrist, or other health care provider licensed to prescribe." Review of the record for resident ID # 10, indicates a current physician's orders [REDACTED]. Review of the Treatment Record reveals that the tube was changed on 9/7/2013, and there is a notation that states " changed w/10 cc Balloon 15 was too much". The facility failed to follow the physician's orders [REDACTED].

Based upon record review and staff interview it was determined that the facility failed to maintain clinical records in accordance with accepted professional standards, i.e., that are legible for 4 of 15 sample residents, (ID #'s 6,9,10, and 13). Findings are as follows: 1. Record review for residents ID# 6, contained 4 physician's progress notes, from March, May, July and October 2013 that were illegible. Additionally the physician's progress notes did not have a resident's name or any identifying information on the document. 2. Record review for resident ID # 9, contained 3 physician's progress notes, from March, April and May 2013, that were not legible. Additionally the physician's progress notes did not have a resident's name or any identifying information on the document. 3. Record review for resident ID # 10, contained 3 physician's progress notes, from May, July and October 2013, that were not legible. Additionally the physician's progress notes did not have a resident's name or any identifying information on the document. 4. Record review for resident ID # 13, contained 4 physician's progress notes, from March, May, July and October 2013 that were not legible. Additionally the physician's progress notes did not have a resident's name or any other identifying information on the document. Interview with the nurse on 11/7/2013 at approximately 10:30 AM, when asked to read the physician's progress notes, she was unable to read the notes, and acknowledged that the notes were not legible. . "You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with applicable provisions of the 'Rules and Regulations for Licensing of Nursing Facilities' they are deficiencies under State Regulations and grounds for licensure sanctions."

Based on surveyor observations, record review and staff interview, it has been determined that the facility has failed to ensure that residents who are fed by a gastrostomy tube receive the appropriate treatment and services to prevent complications for 2 of 2 residents receiving feedings and medications via gastrostomy tube (ID #'s 3 and 13). Findings are as follows: 1. Clinical record review of resident ID # 3 revealed a January 2013 physician order [REDACTED]. Observation during initiation of a tube feeding on 1/14/2013 at 12:00 PM revealed the nurse did not check the placement of the tube prior to starting the tube feeding. Review of the facility's Protocol for [MEDICAL CONDITION] Tube Use dated 1/9/2013 revealed under Nutritional and Technical Aspects of Feeding Tubes: # 5. The placement of the tube.......is to be checked before each use according to the facility protocol and based on current standards of practice. 2. Clinical record review of resident ID # 13 revealed a January 2013 physician's orders [REDACTED]. Observation of the administration of medications to this resident on 1/17/2013 at 9:00 AM revealed the medications were crushed and diluted with water and inserted into the feeding tube following checking the tube for placement. The tube was then capped and replaced. When questioning the nurse at the end of the administration regarding flushing the tube, the nurse acknowledged that the tube should have been flushed following the administration of the medications. Review of the facility's policy dated 1/9/2013 regarding Medication Administration Through a Gastrostomy Tube revealed under Procedure: Flush the tube with at least 30 cc of .... water before and after medications are administered.... When interviewed on 1/17/2013 at 11:30 AM, the Director of Nursing Services indicated that placement of the tube is to be verified before each use and that the tube should be flushed prior to and after administration of medications per current standards of practice and facility protocol. "You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with applicable provisions of the 'Rules and Regulations for Licensing of Nursing Facilities' they are deficiencies under State Regulations and grounds for licensure sanctions."

Based on surveyor observation and staff interview, it was determined that two of three common showers in the facility were not sanitary. Findings are as follows: Surveyor observation of the 1st floor shower on 1/14/2013 revealed the following: - The tile grout along the base of the shower was covered with black matter. - The metal soap and shampoo shower caddy had an accumulation of black matter. The black matter could be easily scraped loose. Surveyor observation of the walk-in shower on the 2nd floor on 1/14/2013 revealed: - The tile grout had areas of black matter. - The pink mesh backing of the shower chair had approximately 18 x 3 inch area of black mold along the bottom edge. There was also a black discolored area approximately 5 x 6 inches in size in the center of the pink mesh backing on the chair. -The plastic supports under the seat of the chair were discolored with orange/pinkish matter and a dark brown substance. -The PVC joints at the base of the chair also had an accumulation of the same orange/pinkish matter. These conditions persisted until 1/16/2013 when the surveyor brought the situation to the attention of the Maintenance Director. The Maintenance Director agreed that these areas were in need of immediate cleaning. Interview with the Maintenance Director on 1/17/2013 at 9:00 AM revealed that although routine cleaning occurs daily, there is no cleaning schedule for the tile grout, chairs or shower equipment.