Inadequate Perineal Care by CNA
Summary
The facility failed to ensure that a certified nurse assistant (CNA) had the appropriate competencies and skill sets to provide proper nursing care, specifically in performing perineal care during a disposable underwear change. This deficiency was identified for one of the four CNAs reviewed for competent nursing care. The incident involved a resident who was cognitively intact and required assistance for activities of daily living due to incontinence of bowel and bladder. The CNA did not follow the facility's policy for perineal care, which requires washing the perineal area from front to back, and only wiped the resident when soiled with fecal matter. The deficiency was brought to the attention of the facility's administration by the resident's responsible representative, who reviewed camera footage showing the CNA's failure to perform proper perineal care. The Director of Nursing (DON) was informed, and an investigation was initiated. The resident was assessed by the Assistant Director of Nursing (ADON) and the Social Worker (SW), with no injuries or distress noted. The CNA admitted to not following the procedure and was subsequently counseled and removed from resident care for re-education.
Penalty
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A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
The facility failed to ensure staff competency in medication administration when an LPN administered Metoprolol to a resident with interstitial lung disease, heart failure, and hypertension without obtaining required vital signs beforehand, despite a physician order to hold the drug for SBP < 100 or HR < 50 and a facility policy and completed competency indicating vital signs must be taken prior to preparing parameter-based medications. This issue was identified in 1 of 5 nurses observed and was determined to have the potential to affect all residents and increase the risk of harm.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
A resident with severe cognitive impairment, multiple cardiac diagnoses, and full code status experienced respiratory distress and became unresponsive, but nursing staff failed to provide competent emergency care in accordance with facility policies. An RN could not determine that the crash cart oxygen tank was empty, did not know how to connect the suction machine, and could not state that a backboard was needed for CPR; competency records showed no evaluation for suction use, vital signs, or emergency response. An LVN reported the resident became weak and was breathing slowly, but did not initiate ventilation, was unable to document vital signs, and paramedics found that staff were not performing CPR, no backboard was in place, and the oxygen regulator delivered only up to 8 L/min. Facility policies required prompt assessment and intervention for respiratory and cardiac symptoms, immediate CPR by trained licensed staff when an individual is unresponsive and not breathing normally, and accurate documentation, as well as sufficient, competent nursing staff, which were not met in this event.
The facility failed to ensure that a CMT had demonstrated competency in resident identification during medication administration and did not complete the required quarterly medication aide evaluations. Despite only one documented evaluation and no evidence of competency in verifying resident identity, the CMT was scheduled to pass medications and entered the wrong room, administering clozapine 150 mg and melatonin 3 mg intended for another resident to a frail, elderly resident with CHF and Afib. The resident, who weighed 79.2 pounds, subsequently developed tachycardia, shortness of breath, altered mental status, profound hypothermia, a small pleural effusion, and aspiration pneumonia, was admitted to the hospital for comfort measures only, and later died. The DON acknowledged that quarterly evaluations were required and could not provide evidence that the CMT had demonstrated competency in medication administration per state requirements.
The facility failed to ensure that staff had required behavioral health competencies and ready access to policies and procedures. Activity assistants assigned to a behavioral health Special Treatment Program entered the unit to assess residents and revise care plans without documented completion of the facility’s required ProACT behavioral health training, despite a policy mandating such training for all staff performing direct care or daily duties on behavioral health units. In addition, multiple CNAs, LVNs, a RT, and unit managers were unable to locate or identify key facility policies, including those for ventilator weaning and resident showers, and reported relying on others or personal experience rather than written P&P. A professional reference cited in the report emphasized that policies must be reviewed, updated, and accessible to guide staff actions and protect resident rights.
Failure to Provide Competent CPR Response and Verify Code Status for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
- Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
- Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
- Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
- Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
- Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved
Failure to Follow Vital Sign Parameters Before Administering Antihypertensive Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a nurse was competent in medication administration according to physician orders and facility policy. The facility’s Medication Administration policy, revised 9/10/25, required that when medications had vital sign parameters, vital signs must be taken prior to preparing the medication. Resident #21, admitted with interstitial lung disease and heart failure, had a physician’s order for Metoprolol Succinate ER 12.5 mg by mouth in the morning for hypertension, with instructions to hold the dose for systolic blood pressure (SBP) less than 100 or heart rate less than 50. On 3/30/26 at 9:35 AM, LPN #2 administered the resident’s medications, including Metoprolol, and only checked the resident’s blood pressure after the medication was given, contrary to the order and policy requiring vital signs beforehand. The CNO confirmed that the nurse should have checked the resident’s vital signs before administering the medication. Review of LPN #2’s oral medication administration competency form showed she had completed training, including the requirement that vital sign parameters be taken per facility practice before pouring medication, yet this was not followed in practice. This failure was identified for 1 of 5 nurses observed during medication administration and was determined to have the potential to affect all residents in the facility and increase the risk of harm to residents.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
Failure to Ensure Competent Nursing Response During Resident Respiratory/Cardiac Emergency
Penalty
Summary
The deficiency involves the facility’s failure to ensure that licensed nursing staff possessed and demonstrated the competencies required to provide emergency care consistent with facility policies and resident assessments. A resident with a POLST indicating full code and full treatment status was admitted for long-term care with diagnoses including diabetes mellitus, congestive heart failure, dementia, and atrial fibrillation. The resident’s MDS showed severe cognitive impairment and dependence on staff for all ADLs, and the care plan identified potential for cardiac distress related to cardiac conditions, directing staff to monitor for symptoms such as dyspnea, shortness of breath, tachycardia, and to promptly notify the physician if symptoms occurred. Physician orders also included PRN oxygen 2–5 L via nasal cannula for shortness of breath or oxygen saturation below 92%. Surveyors found that nursing staff lacked critical emergency response skills and did not follow the facility’s CPR and oxygen administration policies when the resident became unresponsive with difficulty breathing. RN 1 was observed to be unable to determine that the oxygen tank on the crash cart was empty and could not demonstrate how to connect the suction tubing to the suction machine, and later stated not knowing how to check if the oxygen tank was empty or how to connect the suction machine. RN 1 also could not verbalize that a backboard was needed during CPR. Review of RN 1’s competency records showed no skills and competency evaluation for use of a suction machine, vital signs, or emergency response. The DON reported that RN 1 had a language barrier and that she paired RN 1 with experienced LVNs due to RN 1’s comprehension and communication needs. During the resident’s decline, LVN 2 reported that the resident had been stable earlier and had eaten 100% of dinner, but later was weak and breathing slowly. LVN 2 attempted to take vital signs but was unable to document the results and stated that paramedics initiated CPR upon arrival. The Paramedic Captain reported that, on arrival, facility staff were not performing CPR, a backboard was not in place, and the oxygen valve regulator connected to the oxygen tank delivered only up to 8 L/min. LVN 2 stated she was not aware that ventilation could be provided when a resident was unresponsive and breathing slowly and acknowledged inaccuracies in documentation times. Facility policies required assessment of symptoms such as shallow breathing and vital signs during oxygen therapy, immediate initiation of CPR by licensed staff certified in CPR when an individual is unresponsive and not breathing normally (unless a DNR is present), and accurate, time-specific documentation of procedures and treatments. The facility’s staffing policy required sufficient numbers of nursing staff with appropriate skills and competency, which was not met for the involved licensed nurses.
Failure to Ensure CMT Medication Competency and Required Quarterly Evaluations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a Certified Medication Technician (CMT) had the required competencies and quarterly evaluations to safely administer medications, as required by Rhode Island regulations. State regulations mandate that medication technicians must complete a State‑approved course, demonstrate competency in drug administration, and receive quarterly evaluations by the Director of Nursing (DON) or RN designee, with documentation placed in personnel files. The facility’s own assessment stated that department‑specific training and competencies are completed throughout employment to ensure staff can safely and competently provide the required care. However, review of the CMT’s personnel record showed she was hired as a CMT/Nursing Assistant and had only one medication administration evaluation since hire, with no evidence of the four required quarterly evaluations. Record review of the CMT’s “Medication Administration Competency” document showed no evidence that she had demonstrated competency in identifying a resident prior to medication administration. Despite this, she was scheduled to administer medications periodically. On the evening in question, the CMT entered the wrong room and administered medications intended for another resident to Resident ID #1, without verifying the resident’s identity and missing all patient identifiers. The medications administered in error included clozapine 150 mg and melatonin 3 mg, which were prescribed for another resident. Resident ID #1 had been admitted in October 2025 with diagnoses including congestive heart failure and atrial fibrillation and was over a specified advanced age. Following the medication error, a provider note documented that the CMT had administered the wrong medications by entering the wrong room and failing to verify identity, and that the clozapine dose was of significant concern given the resident’s low body weight of 79.2 pounds. The resident subsequently presented to the hospital with elevated heart rate, shortness of breath, and altered mental status, was found to have profound hypothermia, a small left pleural effusion, and aspiration pneumonia, and was admitted for inpatient comfort measures only. The resident later expired. The DON acknowledged that medication aide evaluations are required at least quarterly and was unable to provide evidence that the CMT had demonstrated competency in medication administration per state requirements.
Failure to Ensure Behavioral Health Training and Staff Access to Policies and Procedures
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff working in the behavioral health Special Treatment Program (STP) had the required behavioral health training, and that clinical and direct care staff could locate and reference facility policies and procedures. A complainant reported that Activity Assistants (AAs) were required to enter the STP to assess residents’ activity needs without having the required behavioral health training. The STP Director stated that all employees who worked in the STP were required to complete behavioral health training to ensure staff and resident safety. Review of the facility’s behavioral health training record with the Director of Staff Development showed that AA 1 and AA 3 were not listed as having completed the training, and AA 2 had only participated in the first day of a two‑day behavioral health training program. AA 1, AA 2, and AA 3 confirmed they were required to enter the STP for activity assessments and care plan revisions; AA 1 and AA 3 reported they had requested behavioral health training due to safety concerns but had not received it, despite having worked at the facility from several months to over two years. Further review of training documentation with the DON and Administrator confirmed that only AA 2 appeared on the training list, and that AA 1 and AA 2 had completed only day one of the behavioral health training, with no evidence of completion of day two. There was no documentation of any behavioral health training for AA 3 or AA 4. The facility’s policy titled “ProACT Training & Certification,” dated 8/28/2025, stated that Generations Healthcare provides Professional Assault Crisis Training (ProACT) to all staff involved in direct patient care within behavioral health units, including program staff, nursing staff (RN, LVN, CNA), STP staff, and ancillary staff responsible for daily job duties on behavioral health units where they may interact with behavioral health residents. The policy required all applicable staff providing direct patient care or completing daily job duties on behavioral health units to complete ProACT de‑escalation and restraint training within 90 days of hire. The deficiency also includes the inability of multiple staff members to locate or identify facility policies and procedures (P&P), including those related to ventilator weaning and resident showers. A Unit Manager stated that P&P could be found on the computer but was unable to locate a ventilator weaning policy. A Respiratory Therapist reported not knowing where facility P&P were kept, stated that P&P used to be in a binder whose location he did not know, and was unable to state the current ventilator weaning policy, relying instead on personal experience. Several CNAs and LVNs reported they did not know where P&P were stored and indicated they would ask a nurse or manager if they had questions. Another Unit Manager stated she could ask medical records for P&P. A professional reference from the American Association of Post‑Acute Care Nursing, cited in the report, described that policies should be reviewed annually, revised as regulations change, and stored with documentation of review dates and revision histories, and that policies ensure regulatory expectations are met, resident rights are protected, and staff actions are guided with clarity and consistency.
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