**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, and staff interview the facility failed to ensure that the resident environment remains free of accident hazards as is possible, for 1 of 1 resident reviewed. Specifically, Resident ID #1 who sustained 2nd degree burns (A partial-thickness burn. This type of burn affects both the epidermis and the second layer of skin, which is called the dermis. It may cause swelling and red, white or splotchy skin) from an electric baseboard heating unit. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 11/14/2024 revealed Resident ID #1 was found with his/her foot hanging out of the bed and resting directly on the electric baseboard heating unit. Further review revealed the resident sustained a 2nd degree burn to his/her heel. According to the National Fire Protection Association (NFPA) 70, the National Electrical Code, Article 424, Fixed Electric Space-Heating Equipment, states in part, .424.13 Spacing from Combustible Materials. Fixed electric space-heating equipment shall be installed to provide the required spacing between the equipment and adjacent combustible material unless it is listed to be installed in direct contact with combustible material. Record review revealed an electric baseboard heating unit manufacturers booklet, provided to the surveyor by the facility, states in part, .IMPORTANT INSTRUCTIONS .This heater is hot when in use. To avoid burns, do not let bare skin touch hot surfaces. Keep combustible materials, such as furniture, pillows, bedding, papers, clothes, and curtains away from the heater .Maintain at least 12 inches minimum clearance from all objects above and in front of the baseboard, and 6 inches minimum on both sides . Record review revealed the resident was admitted to the facility in October of 2022 with diagnoses including, but not limited to, neurocognitive disorder with Lewy bodies dementia, muscle wasting and atrophy. Review of a Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 5 out of 15, indicating his/her cognition was severely impaired. Further review revealed the resident required supervision/touching assistance with transfers and required partial to moderate assistance with bed mobility. Review of a progress note dated 11/14/2024 at 5:30 AM, revealed Nursing Assistant (NA), Staff A, found the resident's left foot resting directly on the electric baseboard heating unit. Further review revealed his/her foot was noted to be significantly red, discolored, and swollen, with the following: a burn to his/her left outer heel that measured 15 centimeters (cm) by 7 cm, a burn to the bottom of his/her foot that measured 18 cm by 5 cm, and a burn to his/her left bunion area that measured 10 cm by 5 cm. Additionally, it revealed emergency medical services were called and the resident was transferred to the hospital. During a surveyor interview on 11/15/2024 at approximately 9:00 AM with NA, Staff B, she revealed that at the time of this incident, one side of the resident's bed was pushed up against the wall, where the electric baseboard heating unit was located, with his/her nightstand on the other side of the bed. She further revealed that the majority of residents have their beds pushed up against the walls, where the electric baseboard heating units are located. On 11/15/2024 at approximately 9:30 AM, the surveyor, accompanied by the Maintenance Director, obtained baseboard temperature reading throughout the facility. The readings were taken, utilizing a laser thermometer, registering between 163-190 degrees Fahrenheit. During a surveyor interview on 11/15/2024 with the Maintenance Director, immediately following the above observations of the electric baseboard heating units' temperatures, he acknowledged the above temperature ranges and that they were hot to touch and could only be touched for a few seconds, and further indicated that they get hotter and hotter the longer they are on. He further revealed there should be a 12-inch clearance between the electric baseboard heating units and any furniture. During a surveyor interview on 11/15/2024 at 2:37 PM, with Staff A, she revealed that on 11/14/2024, she had worked the 11:00 PM to 7:00 AM shift. At approximately 2:45 AM, she observed the resident ambulating around his/her room. She further revealed that when she entered the resident's room at approximately 5:00 AM the resident's bed was pushed up against the wall, with his/her left leg hanging off the bed and resting directly on the electric baseboard heating unit. She further revealed that the resident was noted to be in pain as s/he was observed to have facial grimacing but was unable to verbalize the pain. Additionally, she revealed that she was unsure of how long the resident's bed had been placed against the wall. During a surveyor interview on 11/15/2024 at 3:13 PM, with Licensed Practical Nurse, Staff C, she revealed that the resident's bed was positioned up against the wall, near the electric baseboard heating unit. She further revealed that she is unsure how long the resident's bed had been in that position but indicated she had seen the resident's bed up against the wall prior to this incident. She further revealed that the resident did not verbalize any pain, but when his/her foot was being assessed, the resident kept trying to pull it away and was noted to be uncomfortable. Further, she revealed that there are other residents in the facility with their beds pushed up against the walls, near the electric baseboard heating units. Review of hospital documentation dated 11/14/2024 through 11/15/2024 revealed the resident was admitted to the intensive care unit in the hospital with diagnoses including second-degree burns after s/he was found with his/her left foot resting directly on an electric baseboard heating unit at the facility. During a surveyor interview on 11/18/2024 at 1:28 AM, with the Director of Nursing Services, the Regional Infection Control/Wound Nurse, and the Administrator, they were unable to provide evidence that the facility ensured that the resident environment remained as free of accident hazards as possible. The facility failed to ensure that there was a clearance between the resident's bed and the electrical baseboard heating unit which directly placed this resident at risk for serious harm, serious impairment, serious injury or death. Furthermore, as indicated by staff interview there were other beds that were placed up against the walls, where the electrical baseboard heating units are located, which placed these residents at risk serious harm, serious impairment, serious injury or death.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident representative interview and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 5 residents reviewed, Resident ID # 1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 12/30/2022 by Resident ID #1's provider, alleges that the resident went for his/her follow up appointment on 12/30/2022 and presented the medications cards that s/he was taking since discharged from the facility. S/he went on to say that the medications were given to him/her by the facility at the time of discharge. Upon inspection of the medication cards, it was noted by the provider that five of the medication cards were prescribed for another resident, Resident ID #2 and not Resident ID #1. During a surveyor telephone interview on 12/30/2022 at 2:45 PM with Resident ID #1's primary care provider, to obtain additional information relative to this complaint, she revealed that the resident presented to her office on 12/30/2022 and during the visit the resident's spouse presented the 5 following medication cards that the resident was discharged with from the facility. -Eliquis (blood thinner) 5 mg take one tablet two times per day, used to treat, and prevent blood clots. -Diltiazem extended release 120 mg take 1 capsule in the morning for hypertension, used to treat high blood pressure and to control angina (chest pain). -Duloxetine 30 mg (antidepressant) take one capsule daily, used to treat major depressive disorder, generalized anxiety disorder, fibromyalgia, neuropathic pain and central sensitization. -Isosorbide (heart medication) extended release 24-hour capsule 15 mg daily, used for the management of angina (chest pain) in people who have coronary artery disease. -Rosuvastatin (cholesterol medication) 40 mg once a day at bedtime, used to lower bad cholesterol, (LDL and triglycerides) and raise good cholesterol (HDL). Upon inspection of the medication cards, the provider discovered that the medications belonged to another resident at the facility, Resident ID #2. Additionally, the provider indicated that s/he became concerned when Resident ID #1's blood pressure was low on the day of the visit, 100/50 millimeters of mercury (mm Hg), (120/80 mm Hg or lower, is considered normal. A blood pressure reading under 90/60 mm Hg, is abnormally low and is referred to as hypotension). Review of a facility policy titled Discharge Planning Policy last revised on 3/12/2021, states in part, .information to be included in the post discharge plan, reconciliation of medications . Record review revealed Resident ID #1 was admitted to the facility in December of 2022 following a brief acute hospitalization after falling at home. The resident has diagnoses including, but are not limited to, lung cancer, left pneumonectomy (lung removal) and muscle weakness. Review of Resident ID #1's Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 13 indicating the resident is cognitively intact. The resident was discharged from the facility to their home 12 days after his/her admission with visiting nurse services. Review of Resident ID #1's discharge Continuity of Care (COC) form from the facility revealed the following list of medications that the resident would be taking at home: -Aspirin 81 milligrams (mg) one time a day at 8AM, taken to prevent heart attack or stroke. -Calcium Carbonate 500 mg one time per day at 8AM, is a dietary supplement used when the amount of calcium taken in the diet is not enough. -Cholecalciferol (vitamin D) 1000 units one time per day at 8AM, a dietary supplement that is used to treat vitamin D deficiency. -Citalopram 20 mg one time per day for depression at 8PM. -Cyanocobalamin (vitamin B12) 2500 micrograms one time per day at 8 AM, a form of vitamin B used to treat vitamin B12 deficiency. -Folic Acid 0.8mg one time per day at 8AM, is a B vitamin. It helps the body make healthy new cells. -Hydroxyurea (medication used to treat types of cancer) 500 mg one time per day at 8AM. -Magnesium Oxide 400 mg one time a day at 8AM, a form of magnesium commonly taken as a dietary supplement. -Metoprolol extended release 25 mg every evening for hypertension at 8PM, used alone or together with other medicines to treat high blood pressure. - Multivitamin one time a day at 8AM, provide nutrients we don't get from our everyday diet. Further record review failed to reveal evidence of any nursing documentation that medication reconciliation was completed with the resident or his/her representative on the day of the resident's discharge, per the facility's policy. During a surveyor interview with the resident's representative on 12/31/2022 at 9:56 AM, s/he revealed that Registered Nurse, Staff A, handed him/her the resident's medication cards at the desk and told them to follow the directions listed on them. Also, s/he revealed in addition to receiving his/her spouses medication cards, there were an additional 2 medications provided to him/her that were prescribed to Resident ID #2. In addition to the 5 medications mentioned in the complaint, the resident was also given: -Metoprolol extended release 100 mg every morning. -Metoclopramide, (used for stomach and esophagus problems) give one tablet four times a day, is used to help stop you feeling or being sick (nausea or vomiting) including: after radiotherapy or chemotherapy (treatment for cancer) sickness you may get with a migraine. if you've had an operation. Of note, this drug has a black box warning. This is the most serious warning from the U.S. Food and Drug Administration (FDA). A black box warning alerts doctors and patients about drug effects that may be dangerous. Metoclopramide can cause a serious movement disorder called tardive dyskinesia. The resident's representative further indicated that Resident ID #1 had been receiving seven medications daily that were not prescribed for him/her, which were provided to him/her upon his/her discharge from the facility since the evening of 12/22/2022 until the morning of 12/30/2022, when s/he presented to Resident ID #1's primary care provider visit, who identified the medication discrepancies. During a surveyor telephone interview with Registered Nurse, Staff A on 12/31/2022 at 11:45 AM and 12:38 PM, she acknowledged that she completed the resident's discharge on [DATE]. Additionally, Staff A revealed that she did not remember pulling any medication cards for the discharge. She further acknowledged that she did not verify each medication card for accuracy against the resident's discharge orders before providing them to the resident's representative. Staff A was unable to explain how Resident ID #1 was provided with medications that were prescribed for Resident ID #2. Additionally, she acknowledged that she did not complete a medication reconciliation on the day of Resident ID #1's discharge per the facility's policy. During a surveyor observation of the medication cart, in the presence of Medication Technician, Staff B, on 12/31/2022 at 2:00 PM revealed that Resident ID #1 and Resident ID #2's medications had been stored in the same medication cart. Resident ID #2's medications were stored in the same row, directly in front of Resident ID # 1's medications. During the above observation, Staff B indicated that she had worked on the day shift on 12/22/2022 with Staff A. Staff B confirmed that she did not remove any of Resident ID #1's medication cards from the medication cart at the time of the resident's discharge, as this was a nursing responsibility. Record review revealed Resident ID #2 is a current resident at the facility and has the following medication orders: -Eliquis 5 mg take one tablet two times per day -Diltiazem extended release 120 mg take 1 capsule in the morning for hypertension -Duloxetine 30 mg take one capsule daily -Isosorbide extended release 24-hour capsule 15 mg daily -Rosuvastatin 40 mg once a day at bedtime -Metoprolol extended release 100 mg every morning -Metoclopramide give one tablet four times a day (which was discontinued on 10/26/2022) During a surveyor interview with the Administrator and Director of Nursing (DON) on 12/31/2022 at 1:30 PM they were unable to provide evidence that a medication reconciliation had been completed for Resident ID #1 upon his/her discharge from the facility. The DON revealed that it is her expectation that upon discharge the medication reconciliation form is completed and signed by the discharge nurse, and each medication card provided to the resident should be checked against the COC for accuracy upon discharge. Additionally, they acknowledged Resident ID #2 is a current resident at the facility and they were unable to explain why Resident ID #1 was provided with Resident ID #2's medications upon discharge. As a result of this failure Resident ID #1 received 7 medications that were not prescribed to him/her including an anticoagulant medication in which s/he has no known blood clotting issues.