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

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

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

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

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

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

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

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