Coventry Operations Ri Llc Dba Respiratory And Reh
Inspection history, citations, penalties and survey trends for this long-term care facility in Coventry, Rhode Island.
- Location
- 10 Woodland Drive, Coventry, Rhode Island 02816
- CMS Provider Number
- 415078
- Inspections on file
- 41
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 16 (4 serious)
Citation history
Health deficiencies cited at Coventry Operations Ri Llc Dba Respiratory And Reh during CMS and state inspections, most recent first.
A resident with a gastrostomy tube did not receive flushes as ordered by the physician, with documentation and staff interviews confirming that prescribed amounts of water were not administered during medication passes and continuous tube feedings. An LPN reported using less water than ordered, and the physician acknowledged the orders were not followed.
A resident with a tracheostomy and full code status was found unresponsive and pulseless. Staff transferred the resident to a bed and initiated CPR without using a backboard, and rescue breaths via Ambu bag were inconsistently provided, with one staff member delivering fewer than the required breaths per minute and later delegating the task. Emergency personnel arrived to find only chest compressions being performed, and the resident was later pronounced dead at the hospital. The facility could not demonstrate that CPR was performed according to basic life support protocols.
A resident with multiple chronic conditions was given Metolazone 5 mg three times daily instead of the prescribed three times a week due to a transcription error by a nurse. This resulted in the resident receiving excessive doses, leading to fatigue, hypotension, and an unwitnessed fall with severe injuries. The error was confirmed by staff interviews and documentation review, and the facility could not demonstrate compliance with medication administration policies.
Nursing staff failed to demonstrate appropriate competencies in medication management and emergency response, resulting in a significant medication error for a resident and inadequate CPR for another. One resident received an incorrect dosage of Metolazone due to multiple missed verification checks, and staff did not complete required assessments after the error was discovered. Another resident did not receive proper CPR or airway management after being found unresponsive, with staff failing to follow basic life support protocols. Both residents subsequently died.
A resident with hemiplegia, ventilator dependence, and total care needs sustained fractures to the left distal tibia and fibula after a nursing assistant provided incontinence care alone, contrary to the care plan requiring two staff for assistance. The resident rolled out of bed and fell, and the facility could not provide evidence that the care plan was followed.
A resident who was quadriplegic and ventilator-dependent sustained a nasal fracture after an unwitnessed fall from bed when only three NAs were present on the unit, despite facility guidelines requiring more staff. Staff reported being unable to provide adequate supervision due to insufficient staffing, and management was aware of the shortfall but did not adjust assignments or follow their own staffing guidelines.
The facility did not complete or update its facility-wide assessment, resulting in missing documentation and outdated leadership information. A resident experienced two falls and did not receive appropriate care, and concerns were raised about insufficient and unqualified staff. The assessment lacked required supporting records and a current staffing worksheet.
A resident with multiple complex medical conditions sustained a lower leg fracture after a fall and was ordered to have an outpatient orthopedic follow-up. Despite clear documentation and instructions, the facility failed to ensure the resident received the required orthopedic appointment after an initial scheduling attempt was cancelled, resulting in noncompliance with physician orders.
A resident with heart failure, pulmonary hypertension, and chronic kidney disease was readmitted after a hospital stay, and a medication order for Metolazone was incorrectly transcribed by a nurse as three times daily instead of three times a week. The physician reviewed the record but did not identify the error, and the medication reconciliation process was not completed as expected, resulting in the resident receiving the medication in error.
A resident with heart failure, pulmonary hypertension, and chronic kidney disease received Metolazone at a much higher frequency than prescribed due to a transcription error by a nurse, resulting in seven doses being administered over three days instead of the intended two doses. The error was discovered after the resident experienced a fall and was transferred to a hospital, where the resident later passed away. The DON confirmed the medication order was entered incorrectly.
A resident with severe cognitive impairment was mistakenly given another resident's antipsychotic medications by an RN, who failed to properly identify the patient. The error was not communicated to other staff or the resident's family, and the resident was allowed to leave on LOA without monitoring. The assigned LPN did not assess the resident or realize the resident had left, and the provider was not notified until hours later. The resident became unresponsive and required emergency hospitalization and ventilation due to adverse effects from the medication error.
A resident with dementia and multiple comorbidities was mistakenly given another resident's psychiatric medications, including Clozapine and Geodon, by a nurse who failed to properly identify the patient. The error was discovered after the resident became unresponsive while on leave with family, requiring emergency transport, ventilation, and hospitalization for toxic metabolic encephalopathy. The facility did not immediately inform the family or hospital of the medication error, and there was no physician order for the administered drugs.
A resident with multiple health conditions was mistakenly given another resident's antipsychotic medications by an RN. The error was discovered by an LPN, but neither the physician nor the resident's family was promptly notified. The resident's spouse, unaware of the error, took the resident out on LOA, after which the resident became unresponsive and required emergency hospitalization and ventilator support. Staff interviews and record review confirmed the lack of immediate notification.
A resident admitted with multiple pressure ulcers did not receive negative pressure wound therapy as ordered on two occasions, and required wound evaluations were not completed upon admission or weekly as per facility policy. The DON confirmed that documentation and assessments were missing for the specified periods.
The facility failed to provide quarterly financial statements to five residents, as required by regulation. Despite having funds held by the facility, these residents did not receive written accountings of their deposits, withdrawals, and balances. The Business Office Manager and Administrator acknowledged the oversight during interviews.
The facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) and the Notice of Medicare Non-Coverage (NOMNC) to residents as required. Two residents did not receive the SNFABN, and two others did not receive the NOMNC in a timely manner, as confirmed by interviews with the Business Office Manager and Administrator.
A resident was inaccurately assessed with a schizophrenia diagnosis in multiple MDS assessments despite lacking supporting documentation. The MDS Coordinator and Physician Assistant could not provide evidence for the diagnosis, and the Administrator acknowledged the error.
A resident with chronic conditions had an active physician's order for daily weights, which were not obtained over several months. Facility staff, including a nurse and dietitian, were unaware of the order, and the DON acknowledged the oversight, indicating a lapse in communication and adherence to medical directives.
A facility failed to act on a pharmacist's recommendations during a Medication Regimen Review for a resident with COPD and pneumonia. Despite repeated recommendations to clarify stop dates for doxycycline and prednisone, the resident continued receiving these medications for an extended period. The DON could not provide evidence of action on these recommendations, and the resident's physician expected the medications to be adjusted as advised.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with MDROs, as observed by surveyors. Staff were seen providing care without wearing gowns, despite signage indicating the need for EBP. This affected residents with conditions like chronic respiratory failure and those with devices such as G-tubes and tracheostomies. Staff interviews revealed confusion and lack of awareness about EBP requirements.
The facility failed to implement an effective antibiotic stewardship program, resulting in two residents receiving antibiotics without proper review or time-out. A resident with severe sepsis was prescribed antibiotics without an end date, and another with pneumonia received doxycycline for an extended period due to lack of communication and review. Interviews with staff confirmed the absence of a systematic approach to antibiotic monitoring.
A resident with dementia was administered Rexulti without the appointed representative's informed consent. The facility's records lacked documentation of communication regarding the medication's risks, benefits, or alternatives, despite policy requirements. The DON acknowledged the expectation for nurses to inform representatives about treatment changes.
A resident with significant ADL needs was neglected in a LTC facility. Despite requiring assistance with grooming, bathing, dressing, and toileting, the resident reported inadequate care from nursing assistants, leading to a delay in incontinence care. Miscommunication among staff and lack of awareness of assignments contributed to the neglect, as the resident did not receive necessary personal hygiene assistance during the observed shift.
A facility failed to communicate critical changes in a resident's condition to the dialysis center, as required by policy. The resident, with ESRD, experienced a GI bleed and a fall, necessitating a change in transfer status. Staff interviews revealed a lack of awareness about the communication policy, resulting in the dialysis center not being informed of these significant events.
A resident was administered unnecessary medications for an extended period due to the facility's failure to follow discharge orders. Despite recommendations from the Pharmacist to clarify stop dates, the resident continued to receive doxycycline and prednisone beyond their intended duration. Interviews revealed a lack of awareness and oversight by the facility's staff.
The facility failed to document all required components of the facility-wide assessment and did not update it when necessary. The 2025 assessment lacked involvement from key participants, with most listed contributors no longer employed. There was no evidence of input from residents or their representatives. The Administrator could not provide evidence of compliance during an interview.
The facility failed to effectively implement its QAPI program, particularly in infection control and antibiotic stewardship. Staff did not adhere to PPE protocols during high-contact care, and there was no evidence of antibiotic time outs for residents. The DON and Administrator could not demonstrate efforts to address these issues.
A resident with dementia and mobility issues experienced multiple falls, but the facility failed to revise the care plan after a fall in February. Despite adding an intervention for frequent checks, there was no evidence of its implementation, leading to another fall in March. Staff interviews confirmed the oversight.
The facility failed to prevent elopement for three residents identified as at risk. A resident with dementia eloped and was found at a convenience store, with no evidence of interventions or care plan updates. Another resident left unsupervised, despite an evaluation highlighting route dangers, and staff were unaware of the risk. A third resident, with severe cognitive impairment, lacked appropriate interventions, and staff were uninformed of the risk. The facility also failed to conduct required elopement drills.
Surveyors found that the facility failed to maintain a safe and clean environment, with black matter observed on air conditioners and exposed pipes across multiple units. The Maintenance Assistant acknowledged the need for cleaning or service, but the Administrator could not provide evidence of maintaining a homelike environment.
The facility did not provide smoking education to five staff members, including RNs and nursing assistants, as required by their Facility Assessment. This was confirmed during a record review and an interview with the DON, who could not provide evidence of completed training.
The facility did not provide mandatory QAPI training to three staff members, including two RNs and a Nursing Assistant, as revealed by a record review and confirmed by the DON.
The facility did not ensure that all staff completed mandatory behavioral health training, as required by a facility assessment. A review found that a RN and a Nursing Assistant hired in 2023, and another RN hired in 2024, lacked evidence of completing this training. The DON could not provide documentation during a surveyor interview.
The facility failed to administer medications and treatments as ordered for several residents, including those with COPD, quadriplegia, and dementia. Instances included missed doses of Spiriva, Prednisone, Morphine, and Tramadol, as well as neglected trach care and wound treatments. These deficiencies were confirmed during a surveyor interview.
The facility failed to administer prescribed medications to four residents, resulting in significant medication errors. A resident with COPD did not receive their Spiriva and Prednisone, another with vascular dementia missed a Morphine dose, a resident with quadriplegia did not receive Ipratropium-Albuterol, and a resident with chronic pain missed Tramadol. The Market Lead Clinical Specialist could not provide evidence of administration as ordered.
Two residents with stage 4 pressure ulcers did not receive the necessary wound care treatments as ordered by their physicians. A resident's right heel dressing was not changed for seven days, and another resident's sacral wound treatment was missed. The facility's administrator and DON acknowledged these failures during surveyor interviews.
The facility failed to provide necessary respiratory care for residents with tracheostomies, lacking a policy for oral care with suctioning. A resident reported improper administration of mouthwash without suction, and staff interviews revealed inconsistencies in care practices. The deficiency placed residents at risk for serious harm due to potential aspiration and respiratory complications.
A facility failed to ensure nurses had the necessary competencies to care for residents on the Ventilator Unit, leading to an incident where a nurse improperly administered mouthwash to a resident with a tracheostomy without using suction. The resident, who had a complex medical history, was at risk due to the lack of training and competencies among the staff, as confirmed by the facility's administrator.
A resident with a history of atrial fibrillation and peripheral vascular disease experienced new wounds, significant pain, and pitting edema. Despite medical recommendations, the facility administration refused hospitalization, and necessary ultrasounds were not completed in a timely manner. Nursing staff failed to notify the provider of worsening symptoms and did not perform required assessments, leading to the resident's hospitalization with conditions such as peripheral embolization and cellulitis.
The facility failed to follow physician's orders for two residents with indwelling suprapubic catheters. Treatments were not administered as ordered on a specific day, and the DON, who worked as a floor nurse that day, admitted to not completing the treatments due to being too busy passing medications.
The facility failed to ensure that residents with pressure ulcers received necessary treatment and services. Three residents did not receive their prescribed wound care treatments on a specific day, as the Director of Nursing Services, who was working as a floor nurse, was too busy passing medications.
A resident with diabetes and morbid obesity did not receive insulin as ordered on multiple occasions. The DON failed to administer Semglee insulin on one day and did not obtain blood sugar or administer Lispro insulin on another. Additionally, Admelog insulin was incorrectly given when blood sugar levels were below 200.
The facility failed to provide sufficient nurse staffing, resulting in an unlicensed person administering medications and treatments to residents unsupervised. Additionally, a Registered Nurse worked 20 hours in a 24-hour period due to staffing shortages, compromising resident safety and wellbeing.
The facility failed to use its resources effectively and efficiently by allowing an unlicensed graduate nurse to oversee the care of 34 residents during an overnight shift. The GN administered medications, treatments, and completed assessments without proper supervision or a valid nursing license, as confirmed by the Director of Nurses and the Administrator.
A resident with severe abdominal pain, nausea, and vomiting was neglected by an LPN who failed to assess, document, and medicate the resident in a timely manner. The resident's family member had to seek help from the PA and DNS, leading to the resident's transfer to a hospital and diagnosis of acute calculus cholecystitis.
A facility failed to provide necessary behavioral health care for a resident with dementia and anxiety, who exhibited uncontrollable combative behaviors. Despite a care plan and medication, the resident's condition worsened, and effective interventions were not implemented. The nurse did not document the family's refusal for ED transfer or notify the provider of the unchanged behaviors, and a psychiatric consult was not ordered timely.
A resident with severe protein-calorie malnutrition had their G-tube dislodged during medication administration. The facility failed to follow up on inconclusive x-ray results, leading to a 36-hour delay in confirming the G-tube placement. During this time, the resident received no nutrition, hydration, or medications, and the family was not informed.
The facility failed to properly store, distribute, and serve food in accordance with professional standards. Observations revealed undated and improperly stored food in three kitchenettes and one resident room refrigerator. Additionally, a resident's refrigerator, which staff were responsible for monitoring, contained expired food and was not regularly cleaned or temperature-checked as required.
The facility failed to ensure proper medical supervision for a resident with hypothyroidism, resulting in the resident missing 15 doses of Levothyroxine. Despite abnormal TSH levels and physician orders, there was a lack of communication and oversight between the facility and hospice services, leading to inadequate care.
The facility failed to provide sufficient nursing staffing to ensure resident safety and well-being. A resident requiring two staff members for ADL care was observed receiving care from a single nursing assistant. Additionally, significant delays in staff response to call lights were noted. Staff interviews confirmed ongoing staffing challenges, particularly on the vent unit.
Failure to Follow Physician Orders for G-Tube Flushes
Penalty
Summary
The facility failed to meet professional standards of quality by not following physician's orders for gastrostomy tube flushes for a resident with a history of traumatic brain injury, dysphagia, and a gastrostomy tube. Physician orders specified that the feeding tube should be flushed with 30 mL of water before and after each medication pass, at least 15 mL between each medication, and 30 mL prior to feeding, every 4 hours during continuous feeding, and at the end of each feeding. Record review of the Medication Administration Record (MAR) for October revealed that, during medication administration, only 30 mL of water was administered for 91 out of 93 shifts, and during continuous feedings, only 30 mL was administered for 31 out of 33 shifts, with one shift receiving only 22 mL. This documentation did not align with the specific physician orders for flushes. Staff interviews further confirmed the deficiency. An LPN stated that she administered only 15 mL of water before and after medication administration, which did not meet the physician's orders. The physician also acknowledged that the flushes during medication administration and continuous tube feeding were not completed as ordered. These findings were based on a community complaint and subsequent review of records and staff interviews.
Failure to Provide Effective CPR and Basic Life Support
Penalty
Summary
Facility staff failed to provide effective cardiopulmonary resuscitation (CPR) consistent with basic life support protocols to a resident who was found unresponsive, pulseless, and not breathing. The resident, who had a history of acute and chronic respiratory failure with hypoxia and a tracheostomy, was documented as a full code, indicating a desire for all life-saving measures, including CPR. Upon discovery, staff transferred the resident from the toilet to the bed and initiated CPR, with one staff member providing rescue breaths via Ambu bag and another performing chest compressions. An Automated External Defibrillator (AED) was also applied during the resuscitation attempt. Review of documentation and staff interviews revealed that CPR was performed on the bed without the use of a backboard, contrary to best practices for effective chest compressions on soft surfaces. The Director of Nursing Services (DNS) stated that staff should have moved the resident to the floor or used a backboard if CPR was performed on the bed. Additionally, the facility's policy required rescue breaths to be delivered at a rate of 10-12 breaths per minute via Ambu bag for residents with a tracheostomy, but staff interviews and emergency personnel reports indicated that rescue breaths were inconsistently provided, with one staff member admitting to delivering only three breaths per minute and delegating the task to an unidentified staff member at one point. Emergency personnel arrived to find staff performing only chest compressions, with no evidence that rescue breaths or supplemental oxygen were being administered at that time. The resident was subsequently transported to the hospital, where death was pronounced shortly after arrival. The facility was unable to provide evidence that effective CPR, consistent with basic life support protocols and facility policy, was provided throughout the resuscitation effort.
Significant Medication Error Due to Incorrect Transcription of Diuretic Order
Penalty
Summary
A medication error occurred when a resident with a history of heart failure, pulmonary hypertension, and chronic kidney disease was readmitted to the facility with an order for Metolazone 5 mg to be administered three times a week. The order was incorrectly transcribed by a registered nurse to be given three times daily, resulting in the resident receiving seven doses over three days instead of the intended two doses. The facility's policy required medications to be administered according to the prescriber's orders, but this was not followed in this instance. The resident's care plan identified a risk for dehydration related to diuretic medications, with interventions to administer medications as ordered. Progress notes indicated that after the medication error, the resident appeared fatigued and had a low blood pressure reading. Subsequently, the resident was found unresponsive on the floor with significant facial trauma and bleeding, and was transferred to an acute care hospital, where the resident later died. EMS documentation confirmed the resident was not breathing upon their arrival and required resuscitation efforts. Interviews with facility staff, including the nurse who transcribed the order, the DON, and a pharmacist, confirmed the error in transcription and administration of Metolazone. The pharmacist noted that the prescribed frequency was typical and that excessive dosing could lead to adverse effects such as dehydration, lethargy, and hypotension. The facility was unable to provide evidence that it ensured residents were free from significant medication errors, as required by policy.
Failure to Ensure Competent Nursing Staff Leads to Medication Error and Inadequate Emergency Response
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies to provide safe and effective care for all residents, resulting in significant medication errors and inadequate emergency response. In one instance, a resident with a tracheostomy and full code status was found unresponsive and pulseless. Staff initiated CPR on a bed without a backboard, contrary to best practices, and failed to provide rescue breaths at the correct rate as outlined in both facility policy and basic life support protocols. The respiratory therapist delegated rescue breaths to another staff member and could not recall who took over, and emergency personnel found that only chest compressions were being performed when they arrived. The Director of Nursing and Respiratory Therapy Director both confirmed that staff actions did not meet expected standards for CPR delivery. Another resident, also with full code status and multiple comorbidities including heart failure and chronic kidney disease, was readmitted to the facility with a medication order for Metolazone to be given three times a week. The order was incorrectly transcribed as three times daily, and this error was not identified during multiple required medication reconciliation checks by several nurses and the Assistant Director of Nursing. The pharmacy questioned the order, but the nurse responsible failed to verify it with the provider as instructed. The resident received seven doses of Metolazone in three days, and the error was not caught by the provider during a subsequent review. After the error was discovered, new orders were given, including obtaining orthostatic vital signs, but these were not completed before the resident was found unresponsive on the floor with severe hypotension and subsequently died. Additionally, when the second resident was found unresponsive after a fall, staff failed to properly assess and intervene as the resident's condition deteriorated. Despite the resident being face down, unresponsive, and bleeding, staff did not reposition the resident to assess airway or breathing, nor did they initiate CPR or other life-saving measures as the resident's respiratory rate declined. Staff cited facility policy as the reason for not moving the resident, but both the physician and Director of Nursing stated that staff should have stabilized and repositioned the resident to allow for proper assessment and intervention. These failures in medication management, emergency assessment, and CPR delivery demonstrate a lack of sufficient nursing staff with appropriate skill sets, directly impacting resident safety and well-being.
Failure to Follow Care Plan Results in Resident Fall and Fractures
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan, which required two staff members to assist with incontinence care. Despite this intervention being clearly documented in the care plan, a nursing assistant provided care alone, resulting in the resident rolling out of bed and falling. The incident was witnessed, and the resident subsequently complained of severe pain. The resident involved had significant medical needs, including hemiplegia and hemiparesis following a stroke, dependence on a ventilator, and use of both a tracheostomy and gastrostomy. The resident was assessed as totally dependent on staff for all activities of daily living. As a direct result of the failure to implement the care plan, the resident sustained fractures to the left distal tibia and fibula. The facility was unable to provide evidence that staff followed the care plan as required.
Failure to Maintain Sufficient Staffing Resulting in Resident Fall and Injury
Penalty
Summary
The facility failed to maintain sufficient nursing staff to meet the needs of all residents, as evidenced by an incident involving a resident who was quadriplegic, ventilator-dependent, and fully reliant on staff for all care. On the evening in question, the resident experienced an unwitnessed fall from bed resulting in a nasal fracture. Staff interviews and record reviews revealed that only three nursing assistants (NAs) were present on the unit during the shift, despite the facility's own staffing guidelines requiring four to five NAs for that shift. Staff reported being overwhelmed and unable to provide adequate supervision, particularly when multiple staff were occupied with another dependent resident, leaving the rest of the unit unsupervised. Further review showed that the facility's assessment did not specify the average number of staff required to meet resident needs, and management was aware of the staffing shortfall but did not adjust assignments accordingly. The facility was unable to provide evidence that staffing was adjusted based on resident acuity or that their own guidelines were followed. As a result, the resident, who required total assistance, was left without adequate supervision, leading to the fall and injury.
Failure to Complete and Update Facility-Wide Assessment and Staffing Documentation
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. Record review revealed that the facility's assessment, dated March 2025-2026, was incomplete, lacking required supporting documentation and a completed Staffing and Personnel Worksheet. Additionally, the assessment listed a previous employee as the Administrator instead of the current one. During an interview, the current Administrator acknowledged that the assessment was not complete and did not accurately reflect the facility's staffing patterns or leadership. A community complaint reported to the Rhode Island Department of Health alleged that a resident sustained two falls and did not receive appropriate care for their injuries. The complaint also raised concerns about insufficient and unqualified staffing. Review of the facility's documentation confirmed these deficiencies, as multiple sections of the assessment were missing records, and there was no evidence of a current, accurate evaluation of staffing sufficiency or qualifications.
Failure to Ensure Timely Orthopedic Follow-Up After Fracture
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis following a stroke, ventilator dependence, tracheostomy, and gastrostomy was admitted to the facility. The resident sustained a witnessed fall while a nursing assistant was changing their brief, resulting in a complaint of severe pain. Subsequent radiology confirmed a fracture of the distal tibia and fibula, and the resident was placed in a splint at the hospital with orders for an outpatient orthopedic follow-up within one week. Multiple progress notes documented the need for orthopedic follow-up, and nursing staff were instructed to arrange the appointment and send x-ray results to the orthopedic provider. Despite these orders and instructions, record review did not reveal evidence that the resident received the required orthopedic follow-up. Staff interviews indicated that an appointment was initially scheduled but was cancelled by the orthopedic office. The transport aide communicated the cancellation to the physician assistant, who believed the facility staff would reschedule, while the physician assistant stated he does not schedule appointments and expected facility staff to do so. This lack of follow-through resulted in the resident not receiving the ordered orthopedic evaluation.
Failure to Reconcile Medication Orders on Readmission Leads to Medication Error
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician completed a medication reconciliation upon a resident's readmission. The resident, who had diagnoses including heart failure, pulmonary hypertension, and chronic kidney disease, was readmitted after a hospital stay for congestive heart failure exacerbation and respiratory distress. Upon readmission, the hospital discharge documentation ordered Metolazone 5 mg to be administered three times a week. However, a registered nurse incorrectly transcribed this order into the facility's record as three times daily. The resident's physician saw the resident after readmission and reviewed the medical record but did not identify the transcription error regarding the Metolazone order. During interviews, the physician stated that he does not reconcile medication orders between the facility's system and the hospital's continuity of care form, considering it the nursing staff's responsibility. The Director of Nursing Services, however, indicated that it is expected for the provider to reconcile these records to ensure accuracy. This failure resulted in the resident receiving Metolazone in error.
Medication Order Transcription Error Led to Over-Administration
Penalty
Summary
A deficiency occurred when a resident's medication order for Metolazone was incorrectly transcribed in the electronic medical record by a registered nurse. The hospital discharge documentation specified that the resident should receive Metolazone 5 mg by mouth three times a week for 30 days. However, the physician's order entered into the facility's system stated the medication should be given three times a day. As a result, the resident received seven doses of Metolazone over three days, rather than the two doses that were actually ordered. The resident involved had recently been readmitted to the facility with diagnoses including heart failure, pulmonary hypertension, and chronic kidney disease. The error was identified after the resident experienced a fall, was transferred to an acute care hospital, and subsequently passed away. The Director of Nursing Services acknowledged during an interview that the medication order was incorrectly transcribed, leading to the administration of Metolazone at a much higher frequency than prescribed.
Failure to Monitor and Notify After Medication Error Leads to Resident Hospitalization
Penalty
Summary
A resident with multiple medical conditions, including dementia, diabetes, bradycardia, and aortic valve stenosis, was admitted to the facility and had significant cognitive impairment, being rarely or never understood and having severely impaired decision-making skills. On the morning in question, a registered nurse administered another resident's medications, including 200 mg of Clozapine and 80 mg of Geodon, to this resident in error. The nurse failed to properly identify the resident, despite the resident wearing a name band, and the error was only recognized after the medications were ingested. Documentation indicates that the resident remained in the dining area for supposed monitoring, but vital signs were not taken in real time, and the note was not entered until the following day. The nurse assigned to the resident did not assess the resident or ensure monitoring, relying on the other nurse's statement that monitoring had occurred. The facility failed to inform additional staff on the unit about the medication error, so no enhanced monitoring was provided. The resident's family, including the spouse who was present in the facility for about an hour after the error, was not informed of the incident. The resident was allowed to leave the facility on a leave of absence (LOA) with the spouse, who signed the resident out following protocol, but was unaware of the medication error. The nurse assigned to the resident did not review the LOA book and was unaware that the resident had left the facility. Other staff, including nursing assistants, were not informed of the need for monitoring and assisted with the LOA process without knowledge of the error. The provider was not notified of the medication error until approximately nine hours after the incident, after the resident had already been transported to the hospital by emergency medical services due to unresponsiveness. Documentation of vital signs in the resident's record was either delayed or used outdated information from a previous month. The medical director confirmed that the resident should not have been allowed to leave the facility and that no interventions or real-time monitoring were implemented following the error. As a result, the resident experienced adverse effects from the medications, required emergency hospitalization, and was placed on a ventilator for treatment of toxic metabolic encephalopathy.
Resident Hospitalized After Receiving Another Resident's Psychiatric Medications
Penalty
Summary
A significant medication error occurred when a registered nurse administered another resident's psychiatric medications, including 200 mg of Clozapine and 80 mg of Geodon, to a resident who was not prescribed these drugs. The nurse failed to properly identify the resident before administration, despite the resident wearing a name band, and relied on verbal confirmation, which was misunderstood. The error was discovered only after the medications had been ingested, when another staff member familiar with the residents identified the mistake. The affected resident had a complex medical history, including type 2 diabetes, dementia, bradycardia, and aortic valve stenosis, and was severely cognitively impaired, rarely understood, and had both short- and long-term memory problems. After receiving the incorrect medications, the resident became unresponsive while on a leave of absence with family, requiring emergency medical services. The resident was found slumped over, with shallow respirations and low blood pressure, necessitating oxygen, intravenous fluids, and mechanical ventilation during transport to the hospital. Hospital records confirmed the resident was treated for toxic metabolic encephalopathy due to accidental overdose of Clozapine. Facility records showed there was no physician's order for Clozapine or Geodon for this resident, and the error was not immediately communicated to the family or the hospital. The Director of Nursing and the Medical Director acknowledged the failure to follow medication administration policy and the lack of proper resident identification. The incident resulted in the resident being at risk for serious harm, injury, impairment, or death, and required hospitalization and intensive medical intervention.
Failure to Immediately Notify Physician and Family After Medication Error
Penalty
Summary
The facility failed to immediately notify a resident's physician and representative after a significant medication error occurred. A registered nurse administered another resident's antipsychotic medications, including Clozaril 200 mg and Geodon 80 mg, to a resident with multiple medical conditions such as type 2 diabetes, dementia, bradycardia, and aortic valve stenosis. The error was identified by another nurse, but neither the resident's physician nor the resident's family was promptly informed of the incident. The resident's spouse was present in the facility visiting the resident after the medication error but was not informed of the incident by staff. The spouse subsequently took the resident out on a leave of absence, during which the resident became unresponsive and required emergency medical services. The family only learned of the medication error when they returned to the facility to obtain documentation for EMS. Interviews with staff confirmed that the nurse responsible for the resident did not notify the physician or the family immediately after discovering the error, waiting instead until after the family returned to the facility. The Director of Nursing and the Administrator were unable to provide evidence that immediate notification had occurred. The resident required emergency transport, hospitalization, and ventilator support as a result of receiving medications not prescribed for them.
Failure to Provide Timely and Consistent Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, as required by professional standards and facility policy. The resident was admitted with multiple pressure ulcers, including a Stage 4 ulcer and unstageable ulcers, and had physician orders for negative pressure wound therapy to be applied every 72 hours. However, documentation did not show that this therapy was administered as ordered on two specific dates. Additionally, the Treatment Administration Record did not reflect that the negative pressure wound therapy was consistently provided according to the physician's instructions. Further review revealed that a complete wound evaluation for one of the resident's pressure ulcers was not performed upon admission, nor were weekly wound assessments consistently documented as required by the facility's policy and the resident's care plan. The first complete evaluation for the left ischial ulcer was not documented until two weeks after admission, and there was no evidence of weekly wound evaluations during a specified week. The Director of Nursing confirmed that these assessments should have been completed and could not provide evidence that they were done as required.
Failure to Provide Quarterly Financial Statements to Residents
Penalty
Summary
The facility failed to provide a written accounting of deposits, withdrawals, and balances at least quarterly for five residents. These residents, identified by their IDs, had funds held by the facility as evidenced by a document titled 'Trial Balance' dated March 18, 2025. However, there was no evidence of quarterly statements being provided to these residents, which is a requirement per the regulation. During interviews with the Business Office Manager and the Administrator, it was acknowledged that the residents had not received the required quarterly statements. The Administrator was unable to provide evidence of compliance with this requirement for the year 2024, confirming the deficiency in the facility's management of residents' personal funds.
Failure to Provide Required Medicare Coverage Notices
Penalty
Summary
The facility failed to provide proper notice to residents and/or their representatives regarding changes in Medicare coverage, specifically related to the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) of Non-coverage and the Notice of Medicare Non-Coverage (NOMNC). For two residents who were discharged from Medicare Part A services but remained in the facility, there was no evidence that the SNFABN form was issued, as required by Medicare guidelines. These forms are necessary to inform residents when Medicare may not cover certain services, allowing them to make informed decisions about their care and financial responsibilities. Additionally, the facility did not provide the NOMNC in a timely manner for two other residents who were discharged from a Medicare-covered Part A stay with benefit days remaining. The NOMNC is required to be delivered at least two calendar days before the end of Medicare-covered services. Interviews with the Business Office Manager and the Administrator confirmed the lack of evidence for issuing these notices, indicating a failure in the facility's process to comply with Medicare requirements for notifying residents about coverage changes.
Inaccurate Resident Assessment for Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure that the assessment accurately reflected the resident's status for a resident with a diagnosis of schizophrenia. The resident was admitted to the facility in February 2024 with a diagnosis of bipolar disorder, as documented in the Preadmission Screening and Resident Review (PASRR) from January 2024. However, the resident's Admission MDS assessment did not include schizophrenia as an active diagnosis. Subsequent MDS assessments from May 2024, July 2024, October 2024, and January 2025 incorrectly coded the resident with an active diagnosis of schizophrenia. During interviews, the MDS Coordinator admitted to coding the schizophrenia diagnosis on the January 2025 assessment without supporting documentation. The Physician Assistant claimed to have obtained the schizophrenia diagnosis from facility documentation or a consult but could not provide evidence to support this. The Administrator acknowledged that the MDS assessments included a diagnosis of schizophrenia without any supporting documentation, indicating a failure in maintaining accurate resident assessments.
Failure to Follow Physician's Order for Daily Weights
Penalty
Summary
The facility failed to meet professional standards of quality by not following a physician's order for daily weights for a resident. The resident, who was admitted in February 2022, had diagnoses including chronic obstructive pulmonary disease and type 2 diabetes mellitus with diabetic chronic kidney disease. An active physician's order dated 7/31/2024 required daily morning weights for the resident. However, the record review showed no evidence that these weights were obtained from 7/31/2024 through 3/21/2025. Interviews with facility staff revealed a lack of awareness regarding the physician's order for daily weights. A registered nurse and the dietitian both indicated they were unaware of the order. The Director of Nursing Services acknowledged the existence of the order and expressed that it was his expectation for the weights to have been obtained as ordered. This oversight indicates a failure in communication and adherence to physician directives within the facility.
Failure to Act on Pharmacist's Recommendations for Medication Regimen Review
Penalty
Summary
The facility failed to act upon irregularities identified by the Consultant Pharmacist during the monthly Medication Regimen Review (MRR) for a resident admitted with chronic obstructive pulmonary disease (COPD) and bacterial pneumonia. The resident had physician's orders for prednisone and doxycycline, but the pharmacist recommended clarifying a stop date for doxycycline and a stop date or taper order for prednisone. These recommendations were made on multiple occasions, yet the facility did not act on them. As a result, the resident continued to receive doxycycline twice daily from early January through mid-March, totaling 141 doses, and prednisone once daily for the same period, totaling 71 doses. During interviews, the Director of Nursing Services could not provide evidence that the MRR recommendations were followed, and the resident's physician expressed that the prednisone should have been tapered and the doxycycline stopped as per the pharmacist's recommendations.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding the implementation of Enhanced Barrier Precautions (EBP) for residents with multidrug-resistant organisms (MDRO). The deficiency was identified through surveyor observations, record reviews, and staff interviews, affecting four residents who required EBP due to their medical conditions, including chronic respiratory failure, chronic obstructive pulmonary disease, and the presence of devices such as gastrostomy tubes, tracheostomies, urinary catheters, and central lines. For Resident ID #15, the surveyor observed a respiratory therapist removing a nebulizer treatment from the resident's tracheostomy without wearing a gown, despite signage indicating the need for EBP. Similarly, Resident ID #60 was observed receiving a bed bath from a nursing assistant who did not wear a gown, contrary to the posted EBP requirements. Resident ID #74 was transferred and provided hygiene care by staff who also failed to adhere to the gown-wearing protocol, with staff expressing confusion about the necessity of gowns for these activities. Resident ID #92, who required EBP for a G-tube, tracheostomy, wounds, and a central line, was observed receiving central line care and medication administration without the nurse wearing a gown. Staff interviews revealed a lack of awareness and understanding of the EBP requirements, with some staff unaware of the need to wear gowns for specific care activities. The facility's infection preventionist and director of nursing services confirmed the expectation for staff to follow the posted EBP signage, highlighting a gap in adherence to infection control protocols.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an Infection Prevention and Control Program (IPCP) that includes an antibiotic stewardship program with protocols and a system to monitor antibiotic use. This deficiency was identified for two residents, Resident ID #89 and Resident ID #93, who were prescribed antibiotics without evidence of an antibiotic review or time-out. Resident ID #89 was admitted with severe sepsis and septic shock and was prescribed Levofloxacin and Meropenem-Sodium Chloride Intravenous Solution without an end date or evidence of review. Similarly, Resident ID #93, admitted with bacterial pneumonia, continued to receive doxycycline beyond the recommended duration from the hospital discharge summary, resulting in 141 doses instead of the prescribed 4 doses. The facility's failure to conduct antibiotic reviews or time-outs was confirmed through interviews with the Infection Preventionist, Director of Nursing, and the Administrator, who were unable to provide evidence of such reviews for the residents in question. The Director of Nursing acknowledged the discrepancy in the doxycycline order for Resident ID #93, and the physician was not notified of the hospital discharge summary, leading to the extended administration of the antibiotic. These findings highlight the lack of a systematic approach to antibiotic stewardship within the facility, as required by the Centers for Disease Control and Prevention (CDC) guidelines.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to inform a resident's appointed representative about the administration of Rexulti, an atypical antipsychotic medication, and its associated risks and benefits. The resident, who was diagnosed with dementia with psychotic disturbance and had severe cognitive impairment, was unable to provide consent. Despite the facility's policy requiring informed consent for high-risk treatments, there was no evidence that the representative was informed about the addition of Rexulti or any subsequent dosage changes. The resident was readmitted to the facility with a diagnosis of dementia and began receiving Rexulti in January 2025. The medication was administered in increasing doses without notifying the resident's representative. The facility's records, including progress notes and the Medication Administration Record, failed to show any documentation of communication with the representative regarding the medication's risks, benefits, or alternatives. The Director of Nursing Services acknowledged that the nurse should have discussed the treatment plan changes with the representative and documented it accordingly.
Neglect in ADL Care for Resident
Penalty
Summary
The facility failed to protect a resident, identified as Resident ID #452, from neglect concerning their activities of daily living (ADLs). The resident, who was admitted with conditions including anxiety, recurrent depressive disorders, and a urinary tract infection, required significant assistance with ADLs such as grooming, bathing, dressing, toileting, and transfers. Despite these needs, the resident reported that nursing assistants did not provide the necessary care, and only therapists attended to them. On the day of the survey, the resident was observed in a hospital gown, expressing discomfort due to a rash and the need for incontinence care, which was delayed by approximately 48 minutes after the initial call for assistance. The surveyor's observations and interviews revealed a breakdown in communication and responsibility among the staff. Nursing assistants, Staff A and Staff B, indicated they could not transfer the resident without therapy's assistance, although the physical therapist, Staff C, later clarified that no such restriction existed. Additionally, the resident's assigned nursing assistant, Staff E, was unaware of their assignment and did not provide the necessary ADL care, mistakenly believing it was completed by a therapist. This confusion resulted in the resident not receiving assistance with personal hygiene, washing, or dressing during the observed shift. The Director of Nursing Services acknowledged that the nursing assistants should have transferred the resident to provide incontinence care and that all residents should receive necessary ADL assistance, which should be documented. The failure to provide timely and adequate care, as well as the lack of proper documentation and communication among staff, contributed to the neglect of the resident's needs, as highlighted by the surveyor's findings.
Failure to Communicate Critical Changes to Dialysis Center
Penalty
Summary
The facility failed to ensure proper communication with the dialysis center for a resident with end-stage renal disease (ESRD) who required dialysis services. The resident, who was readmitted to the facility with a diagnosis of ESRD, attended dialysis three times a week. Despite the facility's policy requiring communication with the dialysis center regarding changes in the resident's condition, there was no evidence that the dialysis center was informed of the resident's gastrointestinal (GI) bleed or a witnessed fall. The resident had a history of GI bleeds requiring emergency room visits and transfusions, and a recent fall necessitated a change in transfer status to require a Hoyer lift. Interviews with facility staff revealed a lack of awareness regarding the policy to notify the dialysis center of significant changes in the resident's condition. A registered nurse and the Director of Nursing Services both acknowledged the failure to communicate these critical changes, including the GI bleed and fall, to the dialysis center. This oversight indicates a breakdown in the facility's communication processes, as the necessary updates were not included in the dialysis communication binder or records, contrary to the facility's established policy.
Failure to Discontinue Unnecessary Medications
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, as evidenced by the administration of medications beyond their intended duration. A resident was admitted with diagnoses including chronic obstructive pulmonary disease (COPD) and bacterial pneumonia. Upon admission, the Continuity of Care Discharge/Transfer of Patient Form indicated that prednisone and doxycycline were to be discontinued shortly after admission. However, the facility continued to administer doxycycline twice daily from January 7, 2025, through March 19, 2025, totaling 141 doses, and prednisone once daily from January 8, 2025, through March 19, 2025, totaling 71 doses. The Pharmacist had recommended clarifying stop dates for both medications on multiple occasions, but these recommendations were not acted upon. Interviews with the Director of Nursing Services and the Physician Assistant revealed a lack of awareness and oversight regarding the stop dates for these medications. The resident's Physician also expressed that the facility should have followed the orders to discontinue the medications as per the discharge summary. This oversight resulted in the resident receiving unnecessary medications for an extended period.
Facility-Wide Assessment Documentation Deficiency
Penalty
Summary
The facility failed to document all required components of the facility-wide assessment and did not review or update the assessment when changes necessitating substantial modifications occurred. The assessment document for 2025 was undated and unsigned, lacking evidence of active involvement from key participants such as the governing body, Medical Director, Administrator, and Director of Nursing Services (DNS). Of the 13 management staff listed as contributors, 11 were no longer employed at the facility. Additionally, there was no evidence that the facility solicited or considered input from residents, resident representatives, and family members. During an interview, the Administrator could not provide evidence that the facility included all required components or completed necessary changes to the assessment.
Deficiency in QAPI Implementation for Infection Control and Antibiotic Stewardship
Penalty
Summary
The facility failed to implement and maintain an effective Quality Assurance and Performance Improvement (QAPI) program, specifically in the areas of infection control and antibiotic stewardship. The QAPI plan, which was supposed to monitor hand hygiene and personal protective equipment (PPE) compliance, lacked evidence of implementation, tracking, and performance measurement. During surveyor observations, staff were noted to breach infection control practices by not wearing gowns during high-contact care activities for residents under enhanced barrier precautions (EBP). Additionally, the facility's QAPI plan for antibiotic stewardship was not effectively implemented, as there was no evidence of tracking or performance measurement. Record reviews for several residents showed that antibiotic time outs were not completed. During an interview, the Director of Nursing Services and the Administrator could not provide evidence of attempts to address the concerns related to EBP and antibiotic stewardship, indicating a lack of corrective action in these areas.
Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to implement and revise a care plan for a resident identified as being at risk for falls. The resident, who was readmitted to the facility with diagnoses including dementia, difficulty walking, and unsteadiness on feet, experienced multiple unwitnessed falls. On January 5, 2025, the resident sustained a fall and an intervention was added to the care plan to place a bedside mat on the floor. However, after a subsequent fall on February 11, 2025, where the resident attempted to get out of bed unassisted and sustained injuries, the care plan was not revised with new interventions. Further review revealed that on February 12, 2025, the resident was found sitting on the mat next to the bed, leading to an intervention on February 13, 2025, to implement frequent checks when the resident is in bed. Despite this, the resident experienced another fall on March 20, 2025. Interviews with staff, including a Registered Nurse and the Director of Nursing Services, confirmed that the care plan was not updated after the February 11 fall and that there was no evidence that the intervention for frequent checks was implemented.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision to prevent elopement for three residents identified as at risk. Resident ID #1, with a history of dementia and moderate cognitive impairment, eloped from the facility and was found at a local convenience store. Despite being identified as an elopement risk, there was no evidence of interventions or updates to the care plan following a fall outside the facility. The Director of Nursing Services acknowledged the lack of evidence for interventions or staff education on the resident's elopement risk. Resident ID #4, also with dementia and moderate cognitive impairment, was able to leave the facility unsupervised and was found at a convenience store. An occupational therapy evaluation highlighted the dangers of the resident's route, yet there was no update to the care plan to address these concerns. The resident was observed outside the facility unattended, and staff were unaware of the resident's elopement risk, indicating a failure in communication and supervision. Resident ID #2, with severe cognitive impairment, was identified as an elopement risk but lacked appropriate interventions. Staff were unaware of the resident's risk status, and there was no evidence of implemented interventions. The facility also failed to conduct the required elopement drills, as per their policy, further demonstrating a lack of preparedness and oversight in managing residents at risk of elopement.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment as evidenced by surveyor observations and staff interviews. During a survey, it was noted that window air conditioners in multiple rooms across different units, including the North Unit, South Unit, and Memory Care Unit, had diffuse black matter on the air flaps and inside the units. Additionally, the air conditioner in the dining room and air registers in the Memory Care Unit were also observed with heavy accumulations of black matter. Furthermore, exposed piping in the hallway ceiling of the Vent Unit was found with a heavy accumulation of black matter. The Maintenance Assistant acknowledged these observations and admitted that the air registers and air conditioners should be cleaned or taken out of service. However, he was unaware of the black matter on the piping, which would require an outside vendor for replacement. The Administrator was unable to provide evidence that the facility maintained a safe, clean, comfortable, and homelike environment, as required. These findings were based on a community-reported complaint and subsequent surveyor observations.
Failure to Implement Smoking Education for Staff
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for existing staff members regarding smoking education, as outlined in their Facility Assessment dated February 2024. This deficiency was identified during a record review and staff interview, which revealed that five staff members, including two registered nurses and three nursing assistants, did not complete the required smoking education. The staff members in question were hired between February 2023 and July 2024. During an interview with the Director of Nursing Services on August 16, 2024, it was confirmed that there was no evidence of completed smoking education for these staff members.
Failure to Provide Mandatory QAPI Training
Penalty
Summary
The facility failed to provide mandatory training to their staff on the elements and goals of the Quality Assurance and Performance Improvement (QAPI) program. This deficiency was identified during a record review and staff interview, which revealed that three out of five staff members reviewed had not completed the required QAPI training. Specifically, the records did not show evidence of QAPI training for a Registered Nurse hired on September 19, 2023, another Registered Nurse hired on July 5, 2024, and a Nursing Assistant hired on September 18, 2023. During an interview with the Director of Nursing Services, it was confirmed that there was no evidence of completed QAPI training for these staff members.
Failure to Provide Behavioral Health Training
Penalty
Summary
The facility failed to provide mandatory behavioral health training to all staff, as required by a facility assessment. This deficiency was identified during a record review and staff interview, which revealed that three out of five staff members reviewed did not complete the necessary training. Specifically, the records lacked evidence of behavioral health training for a Registered Nurse hired on September 19, 2023, another Registered Nurse hired on July 5, 2024, and a Nursing Assistant hired on September 18, 2023. During an interview with the Director of Nursing Services on August 16, 2024, the surveyor confirmed that the facility could not provide documentation proving that these staff members had completed the required training.
Failure to Administer Medications and Treatments as Ordered
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, as evidenced by the failure to follow physician's orders for seven out of nine residents reviewed. The report highlights multiple instances where medications and treatments were not administered as ordered. For example, a resident with COPD and respiratory failure did not receive their prescribed medications, Spiriva Respimat inhaler and Prednisone, on a specified date. Another resident with vascular dementia and a stage 4 pressure ulcer did not receive their Morphine Sulfate for pain management or the prescribed wound treatment on certain dates. Further deficiencies were noted for residents with complex medical needs, such as a resident with quadriplegia and a tracheostomy who did not receive their prescribed Ipratropium-Albuterol solution or trach care as ordered. Additionally, a resident with chronic pain and rheumatoid arthritis did not receive their Tramadol medication as prescribed. The report also details a resident with anoxic brain damage and an unstageable pressure ulcer who did not receive trach care or wound treatment as ordered on specific dates. The report concludes with findings for residents with dementia and other mental health conditions, where monitoring and administration of medications were not conducted as per physician's orders. These deficiencies were confirmed during a surveyor interview with the Market Lead Clinical Specialist, who could not provide evidence that the residents received their medications and treatments on the specified dates and times.
Significant Medication Errors Identified in Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the lack of administration of prescribed medications to four residents. Resident ID #1, who was admitted with chronic obstructive respiratory disease and respiratory failure, did not receive their prescribed Spiriva Respimat inhaler and Prednisone on the specified date. Similarly, Resident ID #2, diagnosed with vascular dementia, did not receive their prescribed Morphine Sulfate as ordered. Resident ID #3, who has quadriplegia and a tracheotomy, was not administered their prescribed Ipratropium-Albuterol solution. Lastly, Resident ID #4, suffering from chronic pain and rheumatoid arthritis, did not receive their prescribed Tramadol. The deficiencies were identified through a record review and staff interview following a community-reported complaint to the Rhode Island Department of Health. The Market Lead Clinical Specialist was unable to provide evidence that the medications were administered as ordered for these residents. The failure to administer these medications as prescribed constitutes a significant medication error, impacting the care and treatment of the residents involved.
Failure to Provide Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for residents with pressure ulcers, as required by professional standards of practice. Resident ID #1, who was readmitted with a stage 4 pressure injury on the right heel, did not receive the prescribed wound care treatment on two occasions in June 2024. The treatment administration record did not show evidence of the treatment being completed on the specified dates, and the wound dressing was not changed for seven days, as confirmed by the wound physician. The facility's administrator acknowledged the failure to follow the medical doctor's orders during a surveyor interview. Similarly, Resident ID #3, who was admitted with a stage 4 pressure ulcer, did not receive the ordered treatment on a specified date in July 2024. The treatment administration record lacked evidence of the treatment being completed as ordered. The Director of Nursing Services confirmed that the treatments were not completed as ordered and stated that any refusal of treatment by the resident should be documented, and the physician should be notified. These deficiencies indicate a failure to adhere to the facility's policy on skin integrity and wound management.
Failure to Provide Proper Respiratory Care for Residents with Tracheostomies
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards of practice for 15 residents with tracheostomies. The deficiency was identified through surveyor observations, record reviews, and staff interviews. The facility lacked a policy or procedure for performing oral care on residents with tracheostomies, which led to improper care practices. Specifically, a resident alleged that a nurse administered mouthwash without suctioning, which is against the expected practice for residents who are NPO and have tracheostomies. The report highlights that several residents were at risk due to the facility's failure to ensure proper oral care with suctioning. Many residents had complex medical conditions, including dysphagia, chronic respiratory failure, and tracheostomy dependence, which necessitated careful oral care to prevent aspiration and other complications. Despite these needs, the facility did not provide adequate training to staff, resulting in improper care practices, such as the use of mouthwash without suctioning. Interviews with staff revealed inconsistencies in the provision of oral care, with some nursing assistants performing suctioning despite it being outside their scope of practice. The facility's administrator acknowledged the lack of training and policy, which contributed to the improper care. The deficiency placed residents at risk for serious injury, harm, or death due to the potential for aspiration and respiratory complications.
Inadequate Training for Nurses on Ventilator Unit
Penalty
Summary
The facility failed to ensure that licensed nurses had the appropriate competencies and skills to provide safe and effective care for residents on the Ventilator Unit. Specifically, three nurses, identified as Staff A, I, and J, were found to lack training and competencies related to providing suctioning and oral care for residents who are NPO with tracheotomies and may require mechanical ventilation. This deficiency was highlighted by an incident involving a resident with a tracheostomy and locked-in syndrome, who alleged that a nurse forced mouthwash into their mouth without using suction, contrary to the facility's expectations and the resident's care plan. The resident involved had a complex medical history, including cerebral infarction, brain stem stroke syndrome, chronic respiratory failure, and tracheotomy status. Despite the facility's assessment indicating the capability to care for such residents, there was no evidence of a policy or procedure for performing oral care on residents with tracheostomies. Additionally, the facility's administrator confirmed the lack of training or competencies for the involved staff, which contributed to the incident where the resident was subjected to inappropriate oral care practices.
Failure to Promptly Identify and Intervene in Resident's Acute Change in Condition
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice by not promptly identifying and intervening during an acute change in a resident's condition. Resident ID #1, who had a history of atrial fibrillation and peripheral vascular disease, was observed with new wounds on the left great toe and inner ankle, along with significant pain and pitting edema. Despite a physician's assistant recommending hospitalization, the facility administration refused to send the resident to the hospital. Additionally, a STAT X-ray and subsequent ultrasounds were ordered but not completed in a timely manner, and the resident's condition continued to deteriorate without proper intervention. The nursing staff failed to notify the provider of the resident's worsening symptoms, including discoloration and coolness of the lower extremities, and did not complete full assessments or obtain vital signs as required by the facility's policy. The Director of Nursing Services (DNS) acknowledged that the resident should have been assessed every shift for 72 hours following the change in condition but admitted that this was not done. Furthermore, the DNS could not provide an explanation for why the ordered arterial ultrasound was not completed. The resident was eventually sent to the emergency room after significant worsening of symptoms, including discoloration and coolness of both lower extremities, and was diagnosed with conditions such as peripheral embolization and cellulitis. The failure to promptly identify and intervene in the resident's acute change in condition, as well as the lack of proper communication and follow-through on medical orders, led to the resident's hospitalization and further complications.
Failure to Follow Physician's Orders for Suprapubic Catheter Care
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by not following physician's orders for two residents with indwelling suprapubic catheters. Resident ID #7, admitted in May 2023 with diagnoses including obstructive uropathy and benign prostatic hyperplasia, had physician's orders to irrigate the suprapubic catheter with 100 milliliters of normal saline every day and evening shift, and to perform suprapubic care with soap and water and apply a dry protective dressing once daily. However, the May 2024 Treatment Administration Record did not show evidence that these treatments were administered as ordered on 5/20/2024 during the day shift. Similarly, Resident ID #8, admitted in June 2021 with diagnoses including multiple sclerosis and neuromuscular dysfunction of the bladder, had physician's orders to irrigate the suprapubic catheter with 60 milliliters of normal saline three times a day, apply Zinc Oxide External Paste 40% to the buttocks twice daily, and apply Lidocaine External Gel 4% to the suprapubic catheter fistula opening every shift. The May 2024 Treatment Administration Record also failed to show evidence that these treatments were administered as ordered on 5/20/2024 during the day shift. During an interview, the Director of Nursing Services acknowledged that she worked as a floor nurse on that day and did not complete the treatments because she was too busy passing medications.
Failure to Provide Necessary Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice. This deficiency was identified for three residents. Resident ID #4, who was readmitted in April 2024 with an unstageable pressure ulcer, had physician's orders for specific wound care treatments that were not completed on 5/20/2024. Similarly, Resident ID #5, admitted in May 2024 with acute respiratory failure and a right buttock wound, did not receive the ordered wound care treatment on 5/20/2024. Resident ID #6, admitted in April 2024 with an unstageable pressure ulcer, also did not receive the prescribed treatment for bilateral buttocks on the morning of 5/20/2024. During an interview, the Director of Nursing Services acknowledged that she worked as a floor nurse on 5/20/2024 and did not complete any of the required treatments due to being too busy passing medications. This failure to administer the necessary treatments as ordered led to the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing for the affected residents.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to keep a resident free from significant medication errors. The resident, admitted in February 2024 with diagnoses including diabetes and morbid obesity, had several instances where insulin was not administered as ordered. On 5/20/2024, the Director of Nursing Services worked from 7:00 AM to 11:00 PM and failed to administer 16 units of Semglee insulin as prescribed. Additionally, on 5/14/2024 at 6:30 AM, the resident's blood sugar was not obtained, and Lispro insulin was not administered according to the sliding scale order. Further review revealed that the resident received 34 units of Admelog insulin on two occasions (5/4/2024 and 5/6/2024) when their blood sugar levels were below 200, contrary to the physician's order to hold the medication if blood sugar was less than 200. During an interview on 5/22/2024, the Director of Nursing Services could not provide evidence that the insulin was administered correctly on the specified dates and acknowledged the errors.
Insufficient Nurse Staffing and Unlicensed Personnel Administering Medications
Penalty
Summary
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. An unlicensed person, Staff A, was scheduled as a nurse on a unit unsupervised and documented administering treatments and/or medications to multiple residents. Staff A, who graduated from nursing school in 2016 but did not hold an active nursing license, documented administering medications and treatments to residents, including those with chronic respiratory failure, dementia, and other serious conditions. This occurred due to a call-out by the scheduled nurse, and Staff A was left unsupervised on the unit. Additionally, the facility failed to provide sufficient nurse staffing as evidenced by a Registered Nurse, Staff C, working 20 hours in a 24-hour period. Staff C was initially scheduled to work a 12-hour shift but was asked to stay on for additional hours due to a call-out. Despite her concerns about working extended hours, she continued to work to avoid leaving residents without care. The facility's staffing coordinator and nursing weekend supervisor were aware of the staffing challenges but were unable to provide sufficient staff without using agency staff. The Director of Nursing Services (DNS) acknowledged that Staff A, an unlicensed person, documented administering medications and treatments to residents and that Staff C worked 20 hours in a 24-hour period. The DNS was unaware that Staff A was scheduled to work unsupervised and that Staff C had already worked 16 hours before being asked to stay for an additional 4 hours. The facility's inability to provide sufficient nurse staffing compromised resident safety and wellbeing.
Unlicensed Graduate Nurse Worked Unsupervised
Penalty
Summary
The facility failed to be administered in a manner that enables it to use its resources effectively and efficiently, as evidenced by the employment of an unlicensed graduate nurse (GN) who was responsible for overseeing the care of 34 residents during the 11:00 PM - 7:00 AM shift on 5/4/2024-5/5/2024. A community-reported complaint submitted to the Rhode Island Department of Health on 5/7/2024 alleged that this unlicensed GN administered medications to residents on the N3 unit during the specified shift. Record review of the GN's personnel file revealed no evidence of a valid nursing license, nor was there evidence that the facility provided nursing education or completed nursing competencies for this individual. The GN worked unsupervised and documented in 34 residents' electronic medical records, including the administration of medications, treatments, and completion of assessments. During interviews with the Director of Nurses and the Administrator, both acknowledged that the GN was unlicensed and worked unsupervised on the specified shift. The Director of Nurses was unable to provide evidence of the GN's nursing license, and the Administrator confirmed that the GN documented in the residents' medical records without proper supervision. This failure to ensure that the GN was licensed and adequately supervised indicates that the facility did not use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
Failure to Protect Resident from Neglect
Penalty
Summary
The facility failed to protect a resident from neglect, as evidenced by the actions and inactions of an LPN. The resident, who was admitted with diagnoses including Guillain-Barre syndrome, GERD, and anxiety, experienced severe abdominal pain, nausea, and vomiting. Despite the resident's family member's requests for assistance, the LPN ignored the resident's condition and did not assess or medicate the resident for pain. The family member had to seek help from the PA and the DNS, who then intervened. The PA's progress note and interviews revealed that the resident's condition was not communicated by the LPN, and the resident did not receive the prescribed pain medication in a timely manner. The resident was supposed to receive Oxycodone every six hours for severe pain but did not receive the medication until more than two hours after it was due. The PA and the DNS were informed of the neglect by the family member, and the DNS had to reassign the resident's care to another nurse. Further review showed that the resident was eventually transferred to an acute care hospital and diagnosed with acute calculus cholecystitis. The DNS acknowledged that the resident's needs were not met by the LPN and that there was no evidence that the resident was kept free from neglect. The LPN failed to assess the resident's change in condition, document the findings, notify the provider, and administer pain medication as required.
Failure to Provide Appropriate Behavioral Health Care
Penalty
Summary
The facility failed to ensure that a resident diagnosed with dementia and anxiety received appropriate treatment and services to manage behavioral symptoms. The resident exhibited uncontrollable combative behaviors, including hitting staff and refusing care and medication. Despite a care plan indicating the need for behavioral health specialist referrals and monitoring for worsening symptoms, the facility did not implement effective interventions after the prescribed medication was noted to be ineffective. A telehealth evaluation recommended transferring the resident to the Emergency Department (ED), but this was not carried out due to the family's refusal and the facility supervisor's directive against hospital transfers for dementia patients. The nurse on duty did not document the refusal or notify the provider of the resident's unchanged behaviors, nor did she attempt further interventions to manage the resident's agitation and aggression. The Director of Nursing Services (DNS) confirmed that the staff should have notified the provider about the resident's unmanageable behaviors and requested alternative interventions. The facility's records did not show evidence of a psychiatric consult being ordered before the resident's condition worsened, despite a physician's order for a psychiatric consult and treatment. The DNS acknowledged that the facility failed to provide the necessary behavioral health care and services to ensure the resident's highest practicable mental and psychosocial well-being.
Failure to Ensure Proper Care for Resident with Dislodged G-Tube
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube (G-tube) received appropriate treatment and services to prevent complications. The resident, who was admitted with severe protein-calorie malnutrition and was NPO (nothing by mouth), had their G-tube dislodged during a medication administration. Despite a physician's order for an immediate x-ray to confirm the G-tube placement, the facility did not follow up on the inconclusive x-ray results, leading to a delay in confirming the G-tube placement. As a result, the resident went without nutrition, hydration, and medications for approximately 36 hours. During this period, the resident's family was not informed about the dislodged G-tube, and the resident, who was non-verbal and cognitively impaired, was unable to communicate their discomfort. The facility staff, including the Assistant Director of Nursing and the Physician's Assistant, acknowledged the lack of interventions to address the resident's needs while awaiting G-tube placement confirmation. The failure to provide necessary care resulted in the resident experiencing pain and discomfort without any medication, nutrition, or hydration for an extended period.
Improper Food Storage and Monitoring
Penalty
Summary
The facility failed to properly store, distribute, and serve food in accordance with professional standards for food service safety. Surveyor observations revealed multiple instances of improper food storage, including undated and opened food packages in three kitchenettes and one resident room refrigerator. Specifically, non-individually wrapped Fig cookies, ice cream bars, and a container of Breyers chocolate ice cream with freezer burn were found undated. Additionally, an undated bag of waffles and expired raw ground meat were discovered in a kitchenette refrigerator. Staff interviews confirmed the lack of knowledge regarding the dating and proper storage of these items. Further deficiencies were noted in the cleanliness and temperature monitoring of a resident's room refrigerator. The resident, who is legally blind, relies on staff for assistance with the refrigerator. However, the temperature log showed only one recorded temperature for the month, and the interior of the refrigerator contained expired and undated food items, as well as several dried stains. Staff interviews revealed confusion about responsibilities for cleaning and temperature checks, with nursing assistants indicating that nurses were responsible for these tasks. The Interim Director of Nursing was unable to provide evidence that staff were checking the refrigerator temperatures as per physician orders.
Failure to Ensure Proper Medical Supervision for Resident with Hypothyroidism
Penalty
Summary
The facility failed to ensure the medical care of a resident with hypothyroidism was properly supervised by a physician. The resident, who was admitted to the facility in May 2021 and later to hospice services in March 2024, had abnormal TSH levels indicating a need for medication adjustment. Despite a physician's order for Levothyroxine 175 mcg daily, the resident did not receive the medication from February 7, 2024, to February 21, 2024, missing 15 doses. This lapse was noted in the February 2024 Medication Administration Record (MAR) and confirmed by nursing progress notes and lab results showing elevated TSH levels during this period. Interviews with the resident's PA and the hospice nurse revealed a lack of communication and oversight regarding the resident's TSH levels and medication administration. The PA admitted that medication adjustments were deferred to hospice, and the hospice nurse was unaware of the TSH results, indicating a breakdown in collaboration between the facility and hospice services. The Interim Director of Nursing also acknowledged that the PA should have followed up on lab results and could not explain why the resident missed 15 doses of Levothyroxine. This deficiency highlights a failure in ensuring continuous and coordinated medical care for the resident.
Insufficient Nursing Staffing
Penalty
Summary
The facility failed to provide sufficient nursing staffing to ensure resident safety and attain the highest practicable physical, mental, and psychosocial well-being of each resident. Resident ID #21, who was readmitted with diagnoses including dependence on a respirator and stroke, requires the assistance of two staff members for bed mobility and ADL care. However, surveyor observations revealed that care was provided by a single nursing assistant on multiple occasions, contrary to the resident's care plan. Staff interviews confirmed that the resident requires two staff members for care and highlighted the challenges posed by low staffing levels, with one staff member indicating they were responsible for 18-20 residents at a time. Additionally, surveyor observations noted significant delays in staff response to call lights, with response times ranging from 38 to 44 minutes. Interviews with the Interim DON and other staff members acknowledged the ongoing staffing challenges, particularly on the vent unit where most residents require two staff members for care. The facility was unable to provide evidence that they have sufficient nursing staff to ensure resident safety and meet the required standards of care as determined by resident assessments and individual care plans related to ADLs.
Latest citations in Rhode Island
A cognitively impaired resident with dementia and severe BIMS impairment, care planned and ordered to wear a wander guard with regular placement and function checks, eloped from the facility after being last seen in an activity room with a visitor. Staff later could not locate the resident for dinner, and searches were initiated while the resident’s whereabouts were unknown for several hours. Witnesses, including the Activities Director, Receptionist, another resident’s family member, and the visitor, reported that the resident and visitor exited through the main entrance without a wander guard alarm sounding and without use of a door code. The visitor admitted driving the resident to the spouse’s home without notifying staff. EMS and hospital records documented that the resident had been missing for several hours, was confused, could not recall events, and reported severe throat and chest pain, arriving at the hospital with an ankle monitoring device in place. Upon the resident’s return, the facility discarded the original wander guard without testing its functionality and could not provide evidence of consistent monitoring per policy and physician orders, resulting in an Immediate Jeopardy situation.
A resident with Alzheimer’s disease, dementia, severe cognitive impairment, documented exit-seeking behavior, and a care plan identifying high elopement risk and the use of a wander guard was inadequately supervised. Earlier in the day, an LPN observed the resident attempting to open an exit door and redirected the resident, who was later last seen in their room. The resident subsequently exited a secured unit through a stairwell door that only briefly alarmed and was not connected to the wander guard system, descended to a basement level, and left through an exterior door. Because wander guard sensors were only placed at elevators and not at exit doors or stairwells, the resident’s departure went undetected until a Code Orange was called and the elopement protocol initiated, after which staff located the resident off premises and returned the resident to the facility.
A cognitively intact resident with spinal stenosis and post-stroke hemiplegia/hemiparesis was discharged from the hospital with documented referrals to a spine center for evaluation and possible spinal steroid injections, which were reiterated in a later provider note citing ongoing lower extremity weakness. Despite these physician-ordered referrals and the resident’s repeated attempts to reach the appointment scheduler, the facility did not schedule or facilitate the neurosurgical consultation. The unit secretary, who was responsible for scheduling, reported being unaware of the referrals, and neither she nor the DON could provide any evidence that efforts were made to arrange the appointment, leading to a prolonged delay in the resident’s surgical follow-up.
A resident with dysphagia, autonomic dysfunction, seizure disorder, a G-tube, and dependence on staff for feeding had physician orders and a care plan requiring a minced and moist diet with thin liquids given by spoon only while upright. Video from a room camera showed a nurse providing thin liquids through a straw while the resident was lying down and continuing despite the resident coughing. Additionally, a physician ordered every-shift monitoring and documentation of vital signs, including lung sounds, O2 saturation, temperature, and signs of aspiration for seven days, but the MAR showed that required vital signs were not obtained on multiple shifts. The DON confirmed these deviations from physician orders and expected practice.
A resident with intact cognition and a history of hypertension used the call light for toileting assistance when a CNA entered the room and yelled statements such as not "playing games" and telling the resident to wait, causing the resident to become upset. A nursing supervisor heard the CNA yelling, went to the room, and observed the resident visibly upset, while an LPN’s written statement described the CNA’s tone as very rude and yelling about having been with another resident. The CNA later acknowledged speaking loudly to the resident, and during interviews, the administrator and DON could not demonstrate that the resident had been free from verbal abuse as required by the facility’s abuse prohibition policy.
A resident with Alzheimer’s disease receiving hospice services was observed by an RN to be grimacing, with swelling and bruising of the right ankle, and an x-ray later confirmed displaced fractures of the medial and lateral malleolus. Facility policy required that responsible family or legal representatives be notified within 24 hours of significant condition changes or injuries and that this notification be documented in the medical record. A NP documented the fracture findings and ordered that hospice and the resident’s representative be contacted, but there was no documentation that the representative was notified. In interviews, the resident’s representative reported learning of the injuries from hospice staff, the RN acknowledged not notifying the representative, and the DON could not provide evidence that immediate notification occurred, resulting in a deficiency for failure to notify the representative of a significant change in condition.
A resident with Alzheimer's disease, severe cognitive impairment, and non-ambulatory status, receiving hospice care, was found grimacing with swelling and bruising to the right ankle after being brought to the dining room. An x-ray later confirmed acute to subacute displaced fractures of both the medial and lateral malleolus, with no cause identified in the record, making it an injury of unknown origin. A hospice aide reported that during care, the resident became agitated and flailed while two CNAs held the resident's arms and legs, but care was not stopped and the nurse was not notified of the behavior. The RN on duty could not show that the injury of unknown origin was reported to RIDOH, and the DON acknowledged that the incident was not reported, resulting in a failure to report an alleged violation and injury of unknown origin as required.
A non-ambulatory hospice resident with severe cognitive impairment developed swelling and bruising of the right ankle after being taken to the dining room and receiving care in the room, during which the resident became agitated and flailed while a hospice aide and two CNAs continued care and physically held the resident’s arms and legs. An RN later noted the ankle changes, obtained an x-ray order from a provider, and imaging confirmed acute to subacute displaced fractures of both the medial and lateral malleolus. The clinical record and interviews with the RN, DON, and NP showed that no thorough investigation was conducted into the origin of the injury, no potential causes were documented or identified, and no interventions to prevent further or potential injury were documented, despite regulatory requirements and a community complaint alleging lack of notification and unclear cause of the injury.
A resident with CHF, afib, moderate cognitive impairment, and low body weight was mistakenly given another resident’s clozapine 150 mg and melatonin 3 mg by a CMT who entered the wrong room and failed to verify identity, contrary to facility policy requiring multiple resident-identification checks. The resident did not receive ordered warfarin and metoprolol during this pass. Subsequently, the resident was found unresponsive with abnormal respirations, tachycardia, and hypoxia, required EMS intervention with suctioning, high-flow oxygen via BVM, and IV emergency cardiac medication, and was admitted to the hospital with altered mental status, profound hypothermia, pleural effusion, and aspiration pneumonia, later transitioning to comfort care and expiring. The DON was unable to show the resident was kept free from significant medication errors, and the Medical Director stated she expected correct medications to be given to the correct resident.
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.
Elopement of Cognitively Impaired Resident Despite Wander Guard Device
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary supervision and maintain an effective elopement prevention system for a cognitively impaired resident identified as an elopement risk. The resident had diagnoses including dementia, cognitive communication deficit, and anxiety disorder, and a Quarterly MDS showed a BIMS score of 4/15, indicating severe cognitive impairment. The resident’s care plan, initiated after prior attempts to leave the facility, required use of a wander guard bracelet, weekly assessment of the device’s functioning and battery status, and visual checks or supervision for safety. Physician orders directed staff to check placement of the Tektone wander guard bracelet every shift and to check its functionality weekly. Documentation on the March Treatment Administration Record indicated the device was in place on the day of the incident and that its functionality had been checked and found operational several days earlier. On the day of the elopement, staff observed the resident wearing the wander guard bracelet in the activities room during a bingo activity in the mid-afternoon. An LPN reported last seeing the resident in the activity room seated with a visitor and wearing the wander guard. Later, when the LPN attempted to escort the resident to dinner, the resident could not be located, and a subsequent call to the resident’s spouse confirmed that the spouse did not have the resident and was unaware the resident was missing. The facility’s elopement protocol was then initiated, and staff, along with law enforcement, conducted searches of the building and surrounding community. During this time, staff and management did not know the resident’s whereabouts for several hours. Interviews and witness accounts established that the resident exited the facility through the main entrance with a visitor. The Activities Director stated that she did not see the resident or visitor leave and did not hear a wander guard alarm at the exit. The Receptionist reported seeing the resident and a visitor walking toward the main entrance and also did not hear an alarm. A visitor later admitted that she removed the resident from the facility at the resident’s request to go home, drove the resident to the spouse’s house, dropped the resident off, and left without notifying staff; she stated that the wander guard alarm did not sound when they exited and that she had never been given a door code. A family member of another resident reported seeing the visitor leave with the resident through the main entrance without hearing an alarm or seeing a code entered. The resident ultimately arrived at the spouse’s home with a sandwich in hand, appeared confused, and could not explain how they had gotten there. EMS and hospital records documented that the resident had been missing from the facility for several hours, could not recall their whereabouts, and reported severe throat and chest pain; the hospital record also noted that the resident arrived with an ankle monitoring device in place. Following the resident’s return, the facility did not evaluate or test the wander guard device that had been in use at the time of the elopement. A Regional Nurse documented that a new wander guard device was applied to the resident’s left ankle, and later acknowledged in interview that the original device had been discarded without assessment. The Regional Administrator and Regional Nurse were unable to provide evidence that the previous device had been checked or tested for functionality upon the resident’s return. The Administrator stated that it was unclear whether the wander guard system had failed, whether an alarm had sounded without staff response, or whether a visitor had entered a door code, and confirmed that visitors should not have the door code. The facility was also unable to provide documentation confirming that staff consistently monitored the resident in accordance with facility policy and physician orders. These failures resulted in the resident leaving the facility unsupervised for approximately six hours while staff were unaware of the resident’s whereabouts, placing the resident at risk for serious injury, serious harm, serious impairment, or death, and constituted a situation of Immediate Jeopardy.
Failure of Elopement Prevention and Supervision for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and maintain an effective elopement prevention system for a resident assessed as a high elopement risk. The resident had Alzheimer’s disease, dementia, severe cognitive impairment (BIMS score of 00), a documented history of exit-seeking behaviors, and a care plan identifying high elopement risk, prior elopements, recent attempts to leave, verbalizations about leaving, and wandering behavior requiring a wander guard. On the morning of the incident, an LPN observed the resident attempting to open the unit exit door at approximately 9:30 AM; the resident was redirected and escorted back to the dining room. The resident was last seen in their room at approximately 10:00 AM. Despite residing on a secured unit and wearing a wander guard, the resident eloped from the unit via a stairwell door that alarmed when opened but stopped alarming after the door closed and after a period of time. The wander guard system was configured so that sensors were only located at the elevators and did not detect the resident at the unit exit doors or stairwell. The resident used the stairwell to descend several flights to the basement level and exited through a basement exterior door, leaving the building undetected. A Code Orange was not called and the elopement protocol not initiated until approximately 11:20 AM, at which time the resident had already traveled off premises and was later observed walking along a main road and crossing a four-lane street before being located and returned to the facility at approximately 11:45 AM.
Failure to Arrange Neurosurgical Follow-Up for Resident With Spinal Stenosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services were provided in accordance with professional standards of quality for a resident admitted with spinal stenosis and post-stroke hemiplegia/hemiparesis. The resident was admitted in October 2025 with diagnoses including spinal stenosis and left-sided weakness following a stroke. A Continuity of Care - Post-Acute Facility document dated 10/24/2025 indicated that, upon hospital discharge, a referral to a spine center was placed to evaluate the need for spinal steroid injections. A subsequent provider progress note dated 11/17/2025 documented the resident’s ongoing chronic lower extremity weakness related to lumbar disc protrusions and reiterated the need for outpatient neurosurgical follow-up, with an additional referral placed at that time. Record review and interviews showed that, despite these clear and repeated physician-ordered referrals, the facility did not schedule or facilitate the required neurosurgical consultation. The resident, who had a Brief Interview for Mental Status score of 14/15 indicating cognitive intactness and ability to express needs, reported making multiple unsuccessful attempts to contact the facility’s appointment scheduler to obtain the neurosurgical consultation for spinal injections. During an interview, the Unit Secretary responsible for scheduling appointments stated she was unaware of the referrals, and neither she nor the Director of Nursing Services could provide evidence that any efforts were made to arrange the neurosurgical appointment. A community complaint alleged that the resident waited approximately five months without resolution of the needed surgical follow-up appointment.
Failure to Follow Physician Orders for Dysphagia Management and Vital Sign Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of practice and followed physician orders for a resident with significant swallowing difficulties and other complex medical conditions. The resident, admitted with diagnoses including seizure disorder, autonomic dysfunction, presence of a gastrostomy tube, bilateral upper extremity contractures, and dysphagia, was dependent on staff for eating. A physician’s order dated 1/6/2026 specified a house diet with minced and moist texture and thin liquids to be provided by spoon only. The care plan initiated on 12/4/2024 also identified swallowing difficulty and included an intervention to provide thin liquids via spoon. A community complaint and video footage from the resident’s room showed that during an overnight shift, a nurse gave the resident a drink using a straw while the resident was lying down and continued to provide liquids while the resident was coughing, contrary to the physician’s order and care plan. The DON confirmed, after reviewing the video, that the nurse provided thin liquids with a straw while the resident was not upright and continued despite the resident’s coughing. The facility also failed to follow a physician’s order related to monitoring for possible aspiration. A physician’s order dated 3/19/2026 directed staff to obtain and document the resident’s vital signs, including lung sounds, oxygen saturation, temperature, and signs and symptoms of aspiration such as coughing or runny nose, every shift for seven days. Review of the March 2026 Medication Administration Record showed that vital signs were not obtained during the 3:00 PM–11:00 PM and 11:00 PM–7:00 AM shifts on 3/23/2026, and the 11:00 PM–7:00 AM shift on 3/24/2026. In an interview, the DON stated she expected vital signs to be obtained and documented each shift as ordered and acknowledged that the facility failed to ensure physician orders were followed for this resident.
Failure to Protect a Resident From Verbal Abuse by Nursing Assistant
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by a nursing assistant. The resident was admitted with diagnoses including hypertension and had an admission MDS Brief Interview for Mental Status score of 15/15, indicating intact cognition. On the evening in question, after the resident used the call light for toileting assistance, Nursing Assistant Staff A entered the room and yelled, "I'm not playing games with you tonight, you keep pressing the call light, and I told you to wait." The resident reported being upset by this interaction. A Nursing Supervisor, Staff B, who was on duty at the time, responded to the resident’s room after hearing Staff A yelling and observed the resident to be visibly upset. An LPN, Staff C, provided a written statement indicating she heard Staff A speaking in a very rude tone and yelling, "I told you to wait, I was with another resident." Staff A’s own written statement acknowledged that she spoke back to the resident loudly. During an interview with the Administrator and the Director of Nursing Services, they acknowledged the findings and were unable to provide evidence that the resident was free from verbal abuse during this incident, in contrast to the facility’s abuse prohibition policy defining verbal abuse as disparaging or derogatory oral, written, or gestured language within a resident’s hearing.
Failure to Notify Resident Representative of Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s representative of a significant change in condition, specifically an injury of unknown origin resulting in right ankle fractures. The facility’s policy dated 10/19/2023 requires responsible family members or legal representatives to be notified as soon as possible, or within 24 hours, of any changes in the resident’s condition, including significant physical changes and any accidents resulting in injury, with documentation of such notification in the medical record. The resident, admitted in October 2025 with Alzheimer’s disease and receiving hospice services, was observed on 3/9/2026 by an RN to be grimacing after being brought to the dining room, and further assessment revealed swelling and bruising of the right ankle. An x-ray was ordered and later confirmed acute to subacute fractures of the medial malleolus with displacement and a moderately displaced fracture of the lateral malleolus. A subsequent progress note by a nurse practitioner documented the fracture findings and included an order to contact hospice and the resident’s representative to review the results. However, record review did not show any evidence that the resident’s representative was notified by the facility of the injuries, nor was there documentation of such notification in the medical record as required by policy. During interviews, the resident’s representative stated that they were not notified by the facility and instead learned of the injuries from hospice staff. The RN who first identified the bruising and swelling acknowledged that she did not notify the resident’s representative. The Director of Nursing Services was unable to provide evidence that the resident’s representative was immediately notified when the injuries were identified, confirming the failure to follow the facility’s notification policy.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
The facility failed to timely report an injury of unknown origin to the Rhode Island Department of Health (RIDOH) for a resident with Alzheimer's disease who was non-ambulatory, dependent on staff for all transfers, and had severe cognitive impairment. The resident, who was on hospice services, was brought to the dining room by staff and was later observed grimacing, with swelling and bruising to the right ankle. An x-ray obtained that evening confirmed acute to subacute fractures of both the medial and lateral malleolus with displacement. A subsequent nurse practitioner note documented the fracture findings and included an order to contact hospice and the resident's representative, but the clinical record did not identify a cause for the injury, classifying it as an injury of unknown origin. Record review also failed to show that this injury of unknown origin was reported to RIDOH. During interviews, a hospice aide reported that after lunch she provided care to the resident in the room, accompanied by two CNAs. She stated the resident was not in discomfort before care, but became agitated during care and flailed upper and lower extremities, while one CNA held the resident's legs and another held the resident's arms; she did not stop care or notify the nurse of the resident's behavior. After care, the resident was transferred to a chair and returned to the dining room, and the aide later learned of the swollen ankle after returning from lunch, without knowing how the injury occurred. The RN on duty at the time of injury identification was unable to provide evidence that the injury of unknown origin was reported to RIDOH, and the Director of Nursing Services acknowledged that the facility did not report the injury to RIDOH, confirming the failure to report the alleged violation and injury of unknown origin as required.
Failure to Investigate Injury of Unknown Origin and Identify Cause of Ankle Fractures
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an injury of unknown origin for a non-ambulatory resident with Alzheimer’s disease who was dependent on staff for all transfers and had severe cognitive impairment. The resident, who was on hospice services, was brought to the dining room by staff and later exhibited grimacing, with swelling and bruising noted to the right ankle. An x-ray obtained the same day confirmed acute to subacute displaced fractures of both the medial and lateral malleolus. Although the nurse on duty notified the provider and obtained the x-ray order, the clinical record lacked documentation of any investigation into how the injury occurred, any determination or discussion of potential causes, or identification of the origin of the fractures. Surveyor interviews revealed that a hospice aide, accompanied by two CNAs, had taken the resident to the room after lunch to provide care. During care, the resident, who had not shown discomfort beforehand, became agitated and flailed upper and lower extremities while one CNA held the resident’s legs and another held the resident’s arms; care was continued despite the agitation, and the nurse on duty was not notified of this behavior. After care, the resident was transferred to a chair and returned to the dining room, and the hospice aide later learned of the swollen ankle but did not know how the injury occurred. The RN who discovered the swelling and bruising, the DON, and the NP all acknowledged there was no thorough investigation, no documentation establishing the origin of the injuries, and no evidence of implemented measures to prevent further or potential injury, and the facility could not provide investigative findings or evidence of required reporting.
Fatal Medication Error Due to Failure to Verify Resident Identity
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when a Certified Medication Technician (CMT) administered another resident’s medications without verifying identity. On the evening medication pass, the CMT, identified as Staff A, entered the wrong room and gave clozapine 150 mg and melatonin 3 mg, which were prescribed for a different resident, to Resident ID #1. This administration occurred despite a facility policy requiring staff to verify resident identity using methods such as checking an identification band, reviewing a photograph attached to the medical record, and, if necessary, confirming identity with other personnel. All patient identifiers were missed, and the resident did not receive his or her regularly scheduled medications, including warfarin 0.5 mg and metoprolol 12.5 mg. 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. A recent MDS assessment showed moderately impaired cognition with a Brief Interview for Mental Status score of 10 out of 15. The resident weighed 79.2 pounds, and the provider documented that the clozapine dose administered in error was a significant concern given the resident’s small body habitus. Record review confirmed there were no physician orders for clozapine 150 mg or melatonin 3 mg for this resident. Following the medication error, progress notes documented that late on the night of the error, the LPN (Staff B) recorded that the resident had received another resident’s medications and had missed his or her own scheduled warfarin and metoprolol. The next morning, staff found the resident unresponsive with abnormal breathing, pale skin, a heart rate of 136 bpm, and an oxygen saturation of 90%, prompting transfer via EMS. EMS records described the resident as unresponsive with audible gurgling, excessive oral secretions requiring suctioning, a fast and irregular heart rate between 150–190 bpm, and severely depressed respirations requiring bag-valve-mask support and IV emergency heart medication. Hospital records documented elevated heart rate, shortness of breath, altered mental status, profound hypothermia, a chest x-ray showing a small left pleural effusion and aspiration pneumonia, and subsequent transition to end-of-life care, with the resident expiring several days later. During interviews, the DON could not demonstrate that the resident was kept free from significant medication errors, and the Medical Director stated she would have expected the correct medications to be administered to the right resident.
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.
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