Based on record review and staff interview, it has been determined that the facility failed to keep a resident free from physical abuse for 2 of 4 residents reviewed, Resident ID #s 2 and 3. Findings are as follows: Review of a facility policy titled, Abuse Prohibition last revised on 10/31/2022 states in part, It is the policy of this facility to ensure that all residents are treated with respect and dignity and that all residents are free from abuse, mistreatment, neglect .Abuse: willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish . Review of a facility reported incident received by the Rhode Island Department of Health on 8/2/2024 states in part, On 8/1/24 at or around 9pm staff were made aware of an incident when they heard screaming .[Resident ID #1] was found on top of [Resident ID #2] with a sheet over [his/her] head . Record review revealed that Resident ID #1 (perpetrator) was admitted to the facility in September of 2023 with diagnoses including, but not limited to, dementia, anxiety and depression. Review of a Minimum Data Set (MDS) Assessment for Resident ID #1 dated 7/5/2024 revealed a Brief Interview for Mental Status (BIMS) Score of 4 out of 15 indicating severe cognitive impairment. Additional review of the MDS revealed s/he transfers and ambulates independently. Record review revealed that Resident ID #2 (victim) was admitted to the facility in September of 2022 with diagnoses including, but not limited to, breast cancer and anxiety. Review of an MDS Assessment for Resident ID #2 dated 7/12/2024 revealed a BIMS score of 0 indicating severe cognitive impairment. Further review of the MDS revealed Resident ID #2 is non-ambulatory and is dependent for all activities of daily living. Additionally, it revealed that s/he is receiving hospice services. During a surveyor interview via telephone on 8/8/2024, at 10:44 AM with Nursing Assistant (NA) Staff B, she revealed that on 8/1/2024 she witnessed Resident ID #1 in Resident ID #2's bed. Resident ID #1 was on top of Resident ID #2 holding a sheet over his/her face, Resident ID #2 was screaming. Review of second facility reported incident received by the Rhode Island Department of Health dated 8/2/2024 states in part, During our initial investigation the facility was made aware of another resident incident. [Resident ID #3] made a supervisor aware [s/he] was afraid of [Resident ID#1] and said something was put over [his/her] head . Record review revealed that Resident ID #3 (victim) was admitted to the facility in June of 2024 with diagnoses including, but not limited to, dementia, anxiety and depression. Review of an MDS Assessment for Resident ID #3 dated 6/11/2024 revealed a BIMS score of 15 out of 15 indicating intact cognition. Additional review of the MDS revealed s/he requires supervision or touching assistance with transfers and ambulation. Review of a facility provided statement authored by Licensed Practical Nurse, Staff A, dated 8/2/2024 revealed that on 7/31/2024 Resident ID #3 reported feeling scared of his/her roommate (Resident ID #1) and felt like s/he was trying to kill him/her and had put a blanket over his/her face. The statement further revealed that the facility moved Resident ID #3 to another room for safety reasons. During a surveyor interview on 8/8/2024 at approximately 10:00 AM with the Assistant Director of Nursing (ADNS) she revealed that she was made aware of the accusations that Resident ID #3 had made against Resident ID #1 on 7/31/2024. Additionally, she revealed that a room change was made for Resident ID #3. The ADNS further revealed that no additional investigation was completed regarding this allegation on 7/31/2024 or 8/1/2024. The ADNS revealed that she was too busy to investigate the allegation any further. During a surveyor interview on 8/8/2024 at 10:22 AM with the Social Worker, Staff C, she revealed that she was made aware of the accusations by Resident ID #3 against Resident ID #1 on 7/31/2024 and that she made a room change for Resident ID #3. Staff C acknowledged moving Resident ID #2 into same room as Resident ID #1, even though there had been an accusation of abuse made against Resident ID #1. Staff C further revealed that she did not interview Resident ID #1 or Resident ID #3 on the day the allegation was made, as she was too busy to investigate the allegation any further. Review of the census report revealed Resident ID #3 and Resident ID #2 switched beds on 7/31/2024. During a surveyor interview on 8/8/2024 at approximately 10:40 AM with the Regional Director of Nursing, she acknowledged that Resident ID #2 was moved into a room with Resident ID #1, even though Resident ID #1 was accused of being abusive on that same day. Additionally, she was unable to provide evidence that Resident ID #2 had been kept free of abuse. Cross reference F610

Based on record review and staff interview it has been determined that the facility failed to provide evidence that an alleged violation of abuse was investigated, relative to an allegation of resident-to-resident abuse between Resident ID #s 1 and 3, which in turn resulted in Resident ID #2 sustaining abuse by the same alleged perpetrator, Resident ID #1. Findings are as follows: Review of a facility policy titled, Abuse Prohibition last revised on 10/31/2022 states in part, .Any instance of actual or suspected abuse, neglect, mistreatment, involuntary confinement, misappropriation of resident property, including injuries of unknown origins including bruises, skin tears, or lacerations must be reported immediately to the DNS [Director of Nursing Services]/designee, i.e., supervisor on duty and an incident report is filled out .immediate response to allegations and/or incidents may include as appropriate but not limited to, examination of the victim for physical injury, trauma assessment for psychosocial injury, increased supervision of the victim and others as needed, room changes as needed, provision of ongoing emotional support during the investigation and ongoing as needed . Review of a facility reported incident received by the Rhode Island Department of Health dated 8/1/2024 states in part, On 8/1/24 at or around 9pm staff were made aware of an incident when they heard screaming .[Resident ID #1] was found on top of [Resident ID #2] with a sheet over [his/her] head . Review of a second facility reported incident received by the Rhode Island Department of Health dated 8/2/2024 states in part, During our initial investigation the facility was made aware of another resident incident. [Resident ID #3] made a supervisor aware [s/he] was afraid of [Resident ID#1] and said something was put over [his/her] head . Record review revealed that Resident ID #3 was admitted to the facility in June of 2024 with diagnoses including, but not limited to, dementia, anxiety, and depression. Review of a Minimum Data Set Assessment for Resident ID #3 dated 6/11/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Review of a facility provided statement authored by Licensed Practical Nurse, Staff A, dated 8/2/2024 revealed that on 7/31/2024 Resident ID #3 reported feeling scared of his/her roommate (Resident ID #1) and felt like s/he was trying to kill him/her and had put a blanket over his/her face. The statement further revealed that the facility moved Resident ID #3 to another room for safety reasons. During a surveyor interview on 8/8/2024 at approximately 10:00 AM with the Assistant Director of Nursing (ADNS) she revealed that she was made aware of the accusation that Resident ID #3 had made against Resident ID #1 on 7/31/2024. Additionally, she revealed that a room change was made for Resident ID #3. The ADNS further revealed that no additional investigation was completed regarding the allegation Resident ID #3 made on 7/31/2024. During a surveyor interview on 8/8/2024 at 10:22 AM with the Social Worker, Staff C, she revealed that she was made aware of the accusation of abuse made by Resident ID #3 against Resident ID #1 on 7/31/2024 and that she made a room change for Resident ID #3. Staff C further revealed that she did not interview Resident ID #1 or Resident ID #3 on the day the abuse allegation was made. Additionally, she stated that she and did not initiate any type of investigation regarding this allegation of abuse, because she was too busy. Review of the census report revealed Resident ID #3 and Resident ID #2 switched rooms/beds on 7/31/2024. Review of an MDS Assessment for Resident ID #2 dated 7/12/2024 revealed a BIMS score of 0 indicating severe cognitive impairment. Further review of the MDS revealed Resident ID #2 is non ambulatory and is dependent for all activities of daily living (ADL) and is receiving hospice services. During a surveyor interview via telephone on 8/8/2024, at 10:44 AM with Nursing Assistant (NA) Staff B, she revealed that on 8/1/2024 she witnessed Resident ID #1 in Resident ID #2's bed. Resident ID #1 was on top of Resident ID #2 holding a sheet over his/her face, Resident ID #2 was screaming. Additionally, Staff B revealed that she was unaware of the previous abuse allegation that Resident ID #3 had made against Resident ID #1 and was not made aware of it until after she had witnessed Resident ID #1 on top of Resident ID #2 holding a sheet over his/her face. During a surveyor interview on 8/8/2024 at approximately 10:40 AM with the Regional Director of Nursing she acknowledged that there was not an investigation initiated on 7/31/2024 even though Staff A, Staff C and the ADNS were all aware of the abuse allegation reported by Resident #3. The facility's failure to investigate the allegation of abuse made by Resident ID #3 on 7/31/2024, placed Resident ID #2, a vulnerable resident who was cognitively impaired, unable to ambulate, dependent on staff for all of his/her ADLs and receiving hospice services, placed him/her at risk for serious injury, serious harm, impairment or death. Cross reference F600

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it has been determined that the facility failed to ensure that residents who require supervision with meals, received supervision when eating, for 1 of 4 residents reviewed, Resident ID #1. Findings are as follows: Review of a facility reported incident received by the Rhode Island Department of Health on 7/25/2024 revealed that Resident ID #1 experienced a choking incident at 4:17 PM, the Heimlich maneuver (first aid method used when a person is choking) was initiated followed by Cardiopulmonary Resuscitation (CPR). The facility contacted Emergency Medical Services (EMS) and the resident was transported to the Hospital at 5:00 PM where s/he expired. Record review of the EMS report revealed that they were dispatched to the facility for a resident with airway obstruction, who was unconscious and not breathing. The facility communicated with EMS that the resident was eating pizza for dinner in his/her room when s/he choked causing complete airway obstruction and s/he started turning blue. The resident's roommate called for help and the facility staff found the resident actively choking. The facility staff attempted to perform the Heimlich maneuver without success. At this time the resident became unconscious, and the facility staff assisted Resident ID #1 to the floor and chest compressions were started. Per the EMS report the facility staff attempted to manually remove the foreign body via suctioning without success and then proceeded to call 911. When EMS arrived the resident's airway was completely compromised. High quality CPR was being performed by the facility staff and the automated external defibrillator (a device that can help restart a person's heart during cardiac arrest) was attached to the resident and s/he was being passively ventilated. The suction canister next to the resident had blood and secretions in the tubing after the facility staff attempted removal of the foreign body. EMS took over resuscitation efforts and initiated continuous compressions. EMS removed chucks of melted cheese and bread from his/her airway, and they continued to suction copious (large in quantity) amounts of blood and secretions until the airway was patent (open). The procedure took approximately 10 minutes until the airway was completely clear of the obstruction. EMS was unable to intubate due to the copious amount of blood and secretions. Nine rounds of epinephrine (a medication that is used in an emergency to increase blood circulation and breathing) were administered to the resident with no improvement. Resuscitation continued for 30 minutes at the facility and then the resident was transported to the hospital where s/he was pronounced deceased . Record review revealed that Resident ID #1 was readmitted to the facility in October of 2020 with diagnoses including, but not limited to, Barrett's esophagus (a change in the cellular structure of the esophagus lining in which a patient can develop difficulty swallowing), hemiplegia (paralysis in one side of the body), and hemiparesis (muscle weakness on one side of the body) following a stroke, and dementia. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating the resident is cognitively intact. Additionally, the assessment revealed that the resident required supervision of one staff member when eating. Review of a comprehensive care plan revealed the following: -6/14/2024 a focus area indicating that the resident receives a therapeutic mechanically altered diet related in part to dysphagia (difficulty swallowing). Interventions include monitoring, reporting signs and symptoms of dysphagia, and documenting; pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat and/or appearing concerned during meals. -7/20/2024 a focus area for dental care related to the resident being edentulous (having no teeth). Interventions are to monitor for discomfort or difficulty chewing. Review of a physician's order dated 6/7/2022 revealed a consistent carbohydrate diet (CCD), minced and moist in texture. In addition, it includes directions for low lactose, small portions, built up utensils, a plate guard with meals and no carrots. Review of the Speech Therapy Discharge Summary dated 6/4/2024 authored by Speech Language Pathologist (SLP), Staff A, revealed that the resident had a skilled intervention to follow safe swallowing strategies. Additionally, the summary indicates recommendations for a minced and moist textured diet to safely swallow solid foods. Record review of a nursing assistant task document titled ADL [Activities of Daily Living]-Eating, Question 2 describes the following, EATING: SELF PERFORMANCE-How resident eats and drinks, regardless of skill . revealed the following: From 6/30/2024 through 7/25/2024 -For 9 out of 62 opportunities the resident was documented total dependence, full staff performance for eating. -For 30 out of 62 opportunities the resident was documented as needing supervision, oversight, encouragement or cueing for eating. Record review of the progress notes revealed the following: -6/26/2024, a nutritional/dietary note that revealed a quarterly nutritional assessment indicating the resident requires varying levels of assistance from set up to hands on assistance from staff for meals. -7/25/2024, a nursing note authored by Licensed Practical Nurse, Staff G, states in part, At approximately 1617 [4:17 PM] hours, while passing medications, this writer responded to [Resident ID #1] who called out for water. Upon entering the room, the resident was unable to speak and appeared to be choking. I called for help and immediately initiated the Heimlich maneuver. A code blue was initiated, EMS was called. Nurses throughout the building participated in CPR. EMS arrived at 1627 [4:27 PM] hours and took over resuscitation procedures . During a surveyor interview on 7/26/2024 at 1:20 PM with SLP, Staff A, she revealed that the resident was last seen by speech in June of 2024. She indicated that the resident has no teeth, is impulsive, forgetful, and needed reminders to pace him/herself because s/he tends to eat at a fast rate. Additionally, Staff A revealed that whole pizza slices were not a part of the resident's prescribed diet. She further revealed that the resident required assistance and supervision from staff to remind him/her to swallow their food. During a surveyor interview on 7/29/2024 at 2:40 PM with Nursing Assistant, Staff B, she revealed that the resident required supervision for all meals because s/he has a moist and minced modified diet. In addition, she revealed that when the resident desired to have food that was not minced and moist the resident could be easily redirected to get another snack or meal that was appropriate for his/her prescribed diet. During a surveyor interview on 7/30/2024 at 1:13 PM with the resident's child, s/he revealed that s/he could not understand how another resident was allowed to give his/her parent [Resident ID #1] whole slices of pizza without the staff's knowledge, or why they were not monitoring him/her when s/he was eating the pizza, if they were aware s/he had whole slices of pizza. S/he further indicated that his/her stepchild, who works at a pizzeria, brought in a special made pizza for the resident's birthday approximately a week prior. The pizza was prepared moist and minced, as the family was aware of the resident's modified diet. Furthermore, when the pizza was brought into the facility for the resident on his/her birthday, a nurse approved the pizza prior to the resident's consumption, and the family supervised the resident while s/he ate it in its entirety. During a surveyor interview on 7/30/2024 at 3:04 PM, with Registered Nurse (RN), Staff C, she indicated that on 7/25/2024, while she was receiving a nurse to nurse report and preparing to count medications, she saw a pizza delivery person heading towards Resident ID #2's room. Staff C completed the medication count and proceeded to Resident ID #2's room. She discovered that Resident ID #2 had given 2 slices of whole pizza to Resident ID #1. Staff C found Resident ID #1 in his/her room, with 2 whole pizza slices on a plate. Staff C tried to educate the resident about the potential choking hazards of eating pizza, but the resident reacted defensively. She then left the resident unsupervised and went upstairs to inform RN's, Staff D, and E about the situation. After discussing with them, she went back downstairs and discussed the situation with RN, Staff F. At that time someone suggested getting the speech pathologist. Staff C made her way to the speech pathologist's office, but she was not there. Further interview with RN, Staff C revealed that she then returned to Resident ID #1's room and noticed that the resident had almost finished the pizza, as only the crust remained on the plate. She tried to educate the resident but the resident, stated she had pizza for his/her birthday. Staff C stated that she left the resident with the pizza crust on the plate. Later, while preparing to administer pain medication to another resident, she heard another staff member screaming for help and found 3 other nurses in the resident's room where she observed the resident trying to speak but the words were not clear. The Heimlich maneuver was initiated but was unsuccessful and CPR was started. EMS arrived on site, took over CPR and attempted to intubated and suction the resident. EMS finally transported the resident to the hospital after approximately 43 minutes of resuscitation. Additionally, Staff C acknowledged that she left the resident without supervision in his/her room on 7/25/2024 on two occasions, and that she was aware that the pizza was not approved for his/her modified diet of a minced and moist texture. Record review revealed that Resident ID #2 was readmitted to the facility in May of 2024 with diagnoses including, but not limited to, Chronic Obstructive Pulmonary Disease and generalized muscle weakness. Review of an MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating the resident is cognitively intact. During a surveyor interview on 7/26/2024 at 1:40 PM with Resident ID #2, s/he revealed that on 7/25/2024 s/he ordered a pizza. S/he indicated that the delivery person was assisting him/her with the food. Resident ID #1 approached the door and asked for some pizza. Resident ID #2 instructed the delivery person to give 2 slices of pizza to Resident ID #1. Resident ID #1 then took the pizza and returned to his/her room. Resident ID #2 further revealed that s/he informed RN, Staff C, that s/he gave 2 slices of whole pizza to Resident ID #1. Furthermore s/he stated that Staff C told him/her that s/he should not have given the pizza to Resident ID #1. During a surveyor interview on 7/29/2024 at 11:34 AM with the Director of Nursing Services, he acknowledged that the resident expired from choking on slices of whole pizza that the resident consumed. The facility failed to provide Resident ID #1 with adequate supervision while s/he was eating whole pizza slices which is not the resident's ordered diet texture. Staff C was aware that the resident was given whole pizza slices by another resident, and she left the resident unsupervised on two occasions to eat the pizza independently. This failure resulted in Resident ID #1 choking on whole pizza slices, received the Heimlich maneuver and CPR, being suctioned, received 9 rounds of epinephrine and later expired at the hospital.