Greenville Operations Ri Llc Dba Greenville Skille
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenville, Rhode Island.
- Location
- 735 Putnam Pike, Greenville, Rhode Island 02828
- CMS Provider Number
- 415087
- Inspections on file
- 37
- Latest survey
- December 2, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Greenville Operations Ri Llc Dba Greenville Skille during CMS and state inspections, most recent first.
A resident with dementia and malnutrition was admitted with full upper dentures, but staff were unaware of the need for denture care, and documentation did not show evidence of assistance. The facility's oral health policy also lacked required procedures for lost or damaged dentures and did not specify that residents may not be charged for such loss.
Surveyors found that the main kitchen failed to follow professional food safety standards, with mold present in the walk-in refrigerator, dirty storage racks, and food items that were past discard dates or improperly labeled. Additional issues included leaking juice containers and broken eggs, all of which were acknowledged by the Food Service Director and Administrator as not meeting required standards.
Two residents experienced injuries due to the facility's failure to follow safe transfer protocols and implement fall prevention interventions. One resident with dementia and mobility issues was transferred without a walker or gait belt, resulting in a severe leg wound requiring sutures. Another resident with cognitive impairment and a history of falls suffered a hip fracture after an unwitnessed fall, with no new interventions added to the care plan after a prior fall.
A resident with cerebral palsy and intact cognition, who communicates with some difficulty, was held by staff and administered medications via G-tube after repeatedly refusing them. Staff interviews confirmed that a nursing assistant assisted in restraining or distracting the resident while a nurse administered the medications, contrary to facility policy requiring respect for a resident's right to refuse treatment.
Surveyors found deficiencies in the facility's main kitchen, including unclean walls, a dusty fan, and a grimy floor drain, violating the Rhode Island Food Code. Additionally, a spray cleaning bottle lacked proper labeling, breaching OSHA standards. The Regional Executive Chef acknowledged these issues.
The facility failed to monitor dialysis care and fluid restrictions for two residents. One resident with end-stage renal disease was not assessed for their AVF's bruit and thrill, and their MOLST form was not updated. Another resident with stage 4 chronic kidney disease was not monitored for their fluid restriction, leading to potential fluid overload. Staff interviews confirmed the lack of monitoring and documentation.
A resident with dementia and hypotension was administered Midodrine despite having a systolic blood pressure exceeding the physician-ordered parameters. The facility staff, including a registered nurse and the Director of Nursing, acknowledged the failure to follow the order. The resident's physician was unaware of the deviation from the prescribed parameters.
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of antibiotic time-outs for two residents prescribed antibiotics for infections. Additionally, the facility did not have a system to track antibiotic use, including days of therapy, as recommended by the CDC. This was acknowledged by the facility's DNS and Infection Preventionist during interviews.
Two residents with intact cognition did not receive meals according to their preferences, as indicated on their meal tickets. One resident, who dislikes eggs, was served them instead of pancakes, while another resident received a turkey patty instead of a shredded pork sandwich and coleslaw. The facility staff acknowledged these discrepancies, indicating a failure in adhering to meal ticket instructions.
The facility failed to ensure that residents were free from physical restraints not required to treat medical symptoms. Two residents were restrained without proper assessments, consent, or physician orders. Staff members admitted to restraining residents due to fall risk concerns, and the facility's administration confirmed the use of physical restraints and acknowledged the lack of proper documentation.
The facility failed to investigate and report abuse allegations involving two residents, allowing the alleged perpetrators to continue working and resulting in further abuse. Despite immediate reports to an LPN, no action was taken until seven days later, leading to additional incidents of abuse.
A resident with severe cognitive impairment was physically abused and restrained by staff members in the day room. The abuse was reported by another NA, and video footage confirmed the aggressive actions. The resident was found with multiple bruises, and staff admitted to restraining the resident to prevent falls.
The facility's QAPI committee failed to develop and implement plans to correct deficiencies related to resident abuse and rights. Incidents of abuse were not reported or addressed promptly, and the facility did not develop a comprehensive plan to monitor and evaluate performance indicators, leading to Immediate Jeopardies.
The facility failed to ensure staff competency in restraint use, leading to the inappropriate physical restraint of two residents by a nursing assistant and a certified medication technician. The involved staff had not completed mandatory training on restraint and seclusion.
A pharmacist failed to report irregularities in a drug regimen review for a resident with dementia, anxiety, and depression. The resident had a physician's order for Lorazepam without an end date or documented rationale for extended use. The pharmacist's reports from December to April did not identify this issue, and the pharmacist could not provide evidence that the irregularity was reported to the attending physician, Medical Director, and DNS.
A resident with dementia, anxiety, and depression received Lorazepam without a seizure disorder diagnosis. The medication order lacked an end date, and the drug was administered for scratching, not seizures. The LPN and DON confirmed the medication was given incorrectly.
The facility failed to ensure that 5 out of 7 direct care staff members completed mandatory effective communication training for 2023. During an interview, the Regional Nurse, Administrator, and DON could not provide evidence of completed training for these staff members.
The facility failed to provide mandatory QAPI training to all staff. Record review showed that five staff members, including NAs and a Certified Medication Technician, did not complete the required training for 2023. During an interview, the Regional Nurse, Administrator, and DON could not provide evidence of completed training for these staff members.
The facility failed to provide mandatory compliance and ethics training to five staff members, as required. Record review and an interview with the Regional Nurse confirmed the lack of evidence for completed training for these staff members.
The facility failed to provide mandatory behavioral health training to five staff members, including Nursing Assistants and a Certified Medication Technician, as required for 2023. The Regional Nurse, Administrator, and DON confirmed the lack of evidence for completed training.
The facility failed to treat two residents with respect and dignity. One resident was left exposed and aggressively handled by staff, while another was left unattended in a recliner chair. Both residents have severe cognitive impairments and were not properly monitored, as confirmed by staff interviews and video footage.
Failure to Provide Dental Services and Inadequate Denture Loss Policy
Penalty
Summary
The facility failed to provide necessary dental services for a resident with a history of dementia and mild protein calorie malnutrition who was admitted with full upper dentures. Documentation showed that the resident's upper dentures were missing, and staff were unaware that the resident was supposed to have upper dentures. The resident's family reported the missing dentures, and review of the resident's records, including the plan of care and treatment administration record, did not show evidence of assistance or care related to dentures. Interviews with nursing staff revealed uncertainty about whether the resident used dentures, and there was no documentation or physician's order to ensure proper denture care. Additionally, the facility's oral health policy, last reviewed in September, did not include procedures for instances when dentures are lost or damaged, nor did it specify that the facility may not charge residents for such loss or damage as required. The Director of Nursing Services, along with the Administrator and Regional Director, confirmed that the policy lacked this required language and could not provide evidence that the resident received assistance with denture care.
Failure to Maintain Food Safety Standards in Main Kitchen
Penalty
Summary
Surveyor observation, record review, and staff interviews revealed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen. Specific findings included the presence of mold on the walk-in refrigerator walls, dirty racks where food was stored, and food with mold that reportedly went unnoticed for weeks. During a kitchen tour, surveyors observed multiple food items in the walk-in refrigerator that were not properly labeled or dated, including a pan of red beans, fried rice, roasted potato wedges, and tomato soup, all of which were past their discard dates or had illegible labels. Additionally, a pan of red liquid had an illegible label, and there were approximately a dozen orange juice containers that were sticky, wet, and included one open, leaking container. Three broken eggs were also found, with their contents covering the inside of a box containing several dozen whole, raw eggs. The Regional Food Service Director acknowledged that the observed food items should have been discarded after seven days and should have had legible labels with the contents and preparation dates. The Director also confirmed that the leaking orange juice container and broken eggs should have been discarded. The facility Administrator acknowledged the findings in the main kitchen during a subsequent interview. These observations and acknowledgments indicate a failure to adhere to the 2022 FDA Food Code requirements for package integrity and date marking of ready-to-eat, time/temperature control for safety foods.
Failure to Prevent Accidents and Implement Fall Interventions
Penalty
Summary
The facility failed to ensure adequate care and supervision to prevent accidents for two residents. In the first case, a resident with Alzheimer's disease, dementia, and mobility issues sustained a large, deep wound to the left lower leg during a transfer and required hospital evaluation and sutures. Documentation showed the resident required assistance and the use of a walker and gait belt for transfers, as outlined in the facility's Safe Resident Handling/Transfer Equipment policy. However, staff interviews revealed that the transfer was performed without a walker or gait belt, and the staff member assisting was not assigned to the resident and did not remove the resident's clothing, which delayed the discovery of the injury. In the second case, another resident with dementia, muscle weakness, a history of falls, and severe cognitive impairment experienced an unwitnessed fall resulting in a left hip fracture. Prior to this, the resident had a bruise on the left bicep, and a Change in Condition evaluation was completed, but no new fall prevention interventions were implemented as required by the facility's Falls Management policy. Staff interviews confirmed that after the unwitnessed fall and identification of the bruise, no additional interventions were put in place to address the resident's increased fall risk. Both incidents demonstrate a failure to follow established facility policies for safe resident handling and falls management. The lack of proper transfer techniques and failure to update care plans with new interventions after a fall directly contributed to the residents' injuries.
Failure to Honor Resident's Right to Refuse Medication
Penalty
Summary
A resident with diagnoses including cerebral palsy and dysarthria, and with intact cognition as evidenced by a Brief Interview for Mental Status score of 15/15, reported being held down by staff after refusing medications. The resident, who is able to make their needs known but has impaired communication, was admitted with orders allowing medications to be given by mouth if the G-tube was inaccessible. On the date in question, documentation and staff interviews revealed that the resident was combative and refused medications multiple times. Despite this, staff proceeded to administer medications via the resident's G-tube after the resident's repeated refusals. Staff interviews confirmed that a nursing assistant assisted by distracting or holding the resident while a nurse administered the medications. The resident later verbally stated to the surveyor that they had said no repeatedly and did not want the medications, expressing distress over being held down. The Director of Nursing and Administrator confirmed that facility policy requires staff to respect a resident's right to refuse medication and to notify the provider in such cases, which was not followed in this incident.
Deficiencies in Kitchen Cleanliness and Chemical Labeling
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in the main kitchen, as observed by surveyors. During an initial tour, surveyors noted several cleanliness issues, including an accumulation of black matter on the walls of the main kitchen and dish room, a fan in the dish room with approximately one inch of dust and debris, and a floor drain in front of the steamer with about 1.5 inches of thick, grayish-black grime. These observations indicate a failure to maintain nonfood contact surfaces free of dirt, dust, food residue, and other debris, as required by the Rhode Island Food Code 2018 Edition. Additionally, the facility did not comply with labeling requirements for chemical products. A spray cleaning bottle containing a pink substance was found without a label that included a signal word or a statement indicating that full label information was available, as required by the State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities and the Occupational Safety and Health Administration Standard 1910.1200. The Regional Executive Chef acknowledged the need for cleaning the walls, ceiling fan, and floor drain, as well as the labeling deficiency of the spray cleaning bottle.
Failure to Monitor Dialysis Care and Fluid Restrictions
Penalty
Summary
The facility failed to provide appropriate dialysis care for two residents requiring such services. Resident ID #32, who has end-stage renal disease and relies on outpatient dialysis, was not properly monitored for the bruit and thrill of their arteriovenous fistula, with assessments missed on 95 out of 96 opportunities. Additionally, there was a discrepancy in the resident's MOLST form regarding their resuscitation status, which was not updated in the dialysis communication binder. Furthermore, the facility did not implement or monitor a fluid restriction for the resident until it was identified during the survey process. Resident ID #11, diagnosed with stage 4 chronic kidney disease, also received outpatient dialysis but was not monitored for their prescribed daily fluid restriction of 1500 mL. Observations revealed the resident had access to fluids exceeding their restriction, and there was no documentation of fluid intake monitoring until the issue was highlighted by surveyors. Interviews with staff confirmed the lack of monitoring and documentation for both residents' fluid intake, which is critical for their dialysis care.
Failure to Adhere to Medication Parameters for Midodrine Administration
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically regarding the administration of Midodrine. The resident, who was readmitted to the facility in July 2023 with diagnoses including dementia and hypotension, had a physician's order for Midodrine to be administered with specific parameters. The order specified that the medication should be held if the resident's systolic blood pressure (SBP) was greater than 120. However, a review of the Medication Administration Records for November and December 2024 revealed multiple instances where the resident was administered Midodrine despite having an SBP exceeding the specified parameter. Interviews conducted during the survey revealed that the facility staff, including a registered nurse and the Director of Nursing Services, acknowledged the failure to adhere to the physician's order. The resident's physician was also unaware that the medication was being administered outside the prescribed parameters and expressed an expectation that the staff would follow the order as written. This oversight indicates a lapse in the facility's medication administration process, leading to the administration of unnecessary drugs to the resident.
Failure in Antibiotic Stewardship and Monitoring
Penalty
Summary
The facility failed to establish an effective Infection Prevention and Control Program (IPCP) that includes an antibiotic stewardship program, as evidenced by the lack of antibiotic time-outs for two residents. Resident ID #23 was readmitted with sepsis and a urinary tract infection and was prescribed Amoxicillin. However, there was no evidence of an antibiotic time-out being conducted to reassess the need for the antibiotic. Similarly, Resident ID #27, admitted with an infection of the intervertebral disc, was prescribed Ciprofloxacin for a wound infection, but again, no antibiotic time-out was documented. This failure was acknowledged by the Director of Nursing Services, the Infection Preventionist, the Administrator, and the Market Lead Clinical Specialist during a surveyor interview. Additionally, the facility did not have a tracking system for antibiotic use, including days of therapy, as recommended by the CDC's Core Elements of Antibiotic Stewardship for Nursing Homes. The record review of the facility's IPCP did not reveal any evidence of such a tracking system. During an interview, the Infection Preventionist and the Director of Nursing Services admitted they were unaware of the antibiotic days of therapy and did not track them, indicating a gap in monitoring and evaluating antibiotic use within the facility.
Failure to Accommodate Resident Meal Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of two residents, leading to deficiencies in meal service. Resident ID #28, who was admitted with a diagnosis including anxiety disorder and has intact cognition, expressed a dislike for eggs and a preference for pancakes. Despite this, the resident continued to receive eggs during meals. On a specific occasion, the resident was served two boiled eggs instead of the preferred pancakes, as indicated on the meal ticket. The Registered Nurse, Staff B, was unable to explain why the resident's preferences were not followed, indicating a lapse in the dietary aides' adherence to the meal ticket instructions. Similarly, Resident ID #30, who was admitted with a diagnosis including depression and also has intact cognition, did not receive the meal ordered. The resident's meal ticket indicated a preference for a shredded pork sandwich and coleslaw, but instead, a turkey patty was served. The resident reported that this was a recurring issue, with meals often not matching the orders. The Regional Executive Chef acknowledged the discrepancy and confirmed that the meal tickets should reflect the residents' actual meal preferences, highlighting a failure in the facility's meal service process.
Failure to Ensure Residents' Right to be Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints not required to treat medical symptoms. This deficiency was identified for two residents, who were restrained without proper assessments, consent, or physician orders. The facility's policy on restraints clearly states that patients have the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the patient's medical symptoms. However, the facility did not adhere to this policy, as evidenced by the incidents involving the two residents. Resident ID #2 was observed in a recliner chair with multiple obstructions preventing safe exit, including a wall, a table, a chair under the footrest, and another resident's recliner behind. Video footage showed that staff members physically restrained Resident ID #2 by pushing a table against the resident's chest and wedging it between the resident and a support column. Additionally, another resident, Resident ID #7, was also restrained in a recliner chair in a manner that prevented independent movement. Both residents were severely cognitively impaired and required assistance for mobility, yet there were no documented restraint assessments, consent forms, or physician orders for these restraints. Interviews with staff members revealed that the practice of restraining residents in this manner was common due to concerns about fall risks. Staff members admitted to restraining residents under the direction of a Licensed Practical Nurse (LPN), who acknowledged allowing this practice due to safety concerns and inadequate monitoring by staff. The facility's administration confirmed the use of physical restraints on the residents and acknowledged the lack of proper documentation and adherence to the facility's restraint policy.
Failure to Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to provide evidence that all alleged violations of abuse were thoroughly investigated and reported to the State Survey Agency. An incident involving Resident ID #1 occurred on 4/24/2024, where the resident was overheard screaming for help and accusing staff members of hitting them. Despite the immediate report of the incident to a Licensed Practical Nurse (LPN), there was no evidence that the allegation was acted upon immediately. This failure allowed the alleged perpetrators to continue working that evening, leading to another abuse allegation involving Resident ID #2 approximately five hours later. The facility did not begin investigating the initial allegation until 5/1/2024, seven days after the incident occurred. Resident ID #1, who has diagnoses including dementia and anxiety disorder, was admitted to the facility in May 2023. The resident's Minimum Data Set (MDS) assessment indicated severe cognitive impairment. On 4/24/2024, before dinner, the resident was heard screaming for help and accusing staff members of hitting them. Staff members who overheard the incident reported it to the LPN on duty, but there was no immediate action taken to investigate or remove the alleged perpetrators from duty. This inaction allowed the staff members to continue working, resulting in another abuse incident involving Resident ID #2 later that evening. Resident ID #2, admitted in March 2024 with diagnoses including dementia and cognitive communication deficit, was also severely cognitively impaired. On the same evening, staff members were observed physically abusing and restraining Resident ID #2 in the day room. The incident was captured on video footage, which was reviewed by the Administrator and Director of Nursing Services (DNS) on 4/26/2024. The facility's failure to act on the initial abuse allegation involving Resident ID #1 allowed the same staff members to continue working and subsequently abuse Resident ID #2. The Administrator was not made aware of the initial allegation until 5/1/2024, further highlighting the delay in addressing the abuse reports.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse. On 4/24/2024, a Nursing Assistant (NA) and a Certified Medication Technician (CMT) were observed physically abusing and restraining a resident with severe cognitive impairment. The abuse was reported by another NA who overheard the incident and observed the resident being mistreated. Video footage confirmed the aggressive actions of the staff members, including shoving the resident and restraining them with a table against their chest. The resident, who has dementia and a cognitive communication deficit, was admitted to the facility in March 2024. The resident was unable to communicate effectively and was considered severely cognitively impaired. The incident occurred in the day room, where the resident was initially seated in a recliner and later moved to a wheelchair. The staff members involved were seen on video footage aggressively handling the resident, causing physical harm and distress. Interviews with staff members revealed that the abusive actions were not isolated incidents. The staff admitted to restraining the resident as a means of preventing falls, as directed by a Licensed Practical Nurse (LPN). The resident was found with multiple bruises on their arms and legs, indicating ongoing physical abuse. The facility's Administrator and Director of Nursing Services (DNS) acknowledged the failure to protect the resident from abuse and took disciplinary actions against the involved staff members.
Failure to Address Resident Abuse and Rights
Penalty
Summary
The facility's Quality Assessment and Assurance Improvement (QAPI) committee failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to resident abuse and resident rights. On multiple occasions, the facility received deficiencies for failing to protect residents from abuse and failing to report allegations of abuse in a timely manner. Specifically, on 1/24/2024, a housekeeper was observed kissing a resident, and the incident was not reported promptly. On 2/19/2024, staff failed to provide incontinence care, which was also not addressed adequately. Despite providing education to nursing staff, the facility did not develop a comprehensive plan to monitor and evaluate performance indicators to ensure sustained corrections or necessary revisions. Further incidents occurred on 4/24/2024, where a Nursing Assistant reported allegations of abuse involving two staff members and two residents. One resident was heard yelling and a bang noise was reported, while another resident was overheard screaming for help and pleading not to be hit. The facility failed to act immediately on these allegations, allowing the involved staff members to continue working. During an interview, the Administrator and Director of Nursing Services admitted that they had only provided education to nursing staff and had not developed a QAPI plan to monitor and evaluate performance indicators. This failure led to Immediate Jeopardies, as the facility did not keep residents free from physical abuse and restraints, nor did it report and investigate allegations of abuse promptly.
Failure to Ensure Staff Competency in Restraint Use
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies to provide safe care, as evidenced by an incident involving the physical restraint of two residents. On 4/24/2024, video footage showed that a nursing assistant and a certified medication technician restrained Resident ID #2 by placing a table against the resident's chest and positioning another resident's recliner to block movement. This method of restraint was acknowledged by the facility's administration and was reportedly used frequently to prevent falls, despite being inappropriate and unsafe. Additionally, Resident ID #7 was also restrained in a manner that prevented independent movement. The facility's records revealed that several staff members, including those involved in the incident, had not completed mandatory training on restraint and seclusion. This lack of training was confirmed during interviews with the facility's administration and the regional nurse. The facility's assessment indicated that education on physical restraints was provided, but there was no evidence that the required training had been completed by the staff members involved in the incident.
Pharmacist Failed to Report Drug Regimen Irregularities
Penalty
Summary
The pharmacist failed to report irregularities in the drug regimen review for a resident admitted in January 2021 with diagnoses including dementia, anxiety, and depression. The resident had a physician's order for Lorazepam Oral Concentrate 2 MG/ML, to be administered as needed for seizures lasting more than 5 minutes, without an end date or documented rationale for extending the duration of use. The resident received the medication once in May 2024. The pharmacist's consultation reports from December 2023 to April 2024 did not identify the missing end date. During an interview, the pharmacist confirmed the completion of the consultation reports but could not provide evidence that the irregularity was reported to the attending physician, the Medical Director, and the DNS as required.
Failure to Ensure Drug Regimen Free from Unnecessary Psychotropic Drugs
Penalty
Summary
The facility failed to ensure a resident's drug regimen was free from unnecessary psychotropic drugs. The resident, admitted in January 2021 with diagnoses including dementia, anxiety, and depression disorder, had a physician's order dated December 1, 2023, for Lorazepam Oral Concentrate 2 mg/ml, to be given 1 ml by mouth every 24 hours as needed for a seizure lasting more than 5 minutes. However, the order lacked an end date or a documented rationale for extending the duration of use. The resident received the medication on May 1, 2024, despite not having a diagnosis of a seizure disorder or any history of seizure activity. The medication was administered because the resident was scratching their arms, which was not the intended purpose of the medication order. During interviews, the LPN who administered the medication confirmed that the resident did not have a seizure disorder and that the medication was given for scratching. The Director of Nursing Services acknowledged that the order had no end date and that the medication was administered for an incorrect purpose. This failure to adhere to proper medication protocols resulted in the resident receiving unnecessary psychotropic medication.
Failure to Complete Mandatory Communication Training
Penalty
Summary
The facility failed to ensure that all direct care staff completed mandatory effective communication training for 5 out of 7 staff reviewed. Specifically, there was no evidence that Staff D, E, G, H, and I completed the required training for 2023. Staff D, a Nursing Assistant (NA), was hired on 9/22/2009; Staff E, a Certified Medication Technician, was hired on 8/18/2009; Staff G, an NA, was hired on 6/12/2022; Staff H, an NA, was hired on 10/6/2016; and Staff I, an NA, was hired on 6/10/2016. During an interview with the Regional Nurse, in the presence of the Administrator and Director of Nursing Services, they were unable to provide evidence that the training was completed for these staff members.
Failure to Provide Mandatory QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training to all staff on the elements and goals of the Quality Assurance and Performance Improvement (QAPI) program. Record review revealed that five out of seven staff members reviewed, specifically Staff D, E, G, H, and I, did not complete the required QAPI training for 2023. Staff D, a Nursing Assistant (NA), was hired on 9/22/2009; Staff E, a Certified Medication Technician, was hired on 8/18/2009; Staff G, an NA, was hired on 6/12/2022; Staff H, an NA, was hired on 10/6/2016; and Staff I, an NA, was hired on 6/10/2016. During an interview with the Regional Nurse, Administrator, and Director of Nursing Services, they were unable to provide evidence that the training was completed for these staff members.
Failure to Provide Mandatory Compliance and Ethics Training
Penalty
Summary
The facility failed to provide mandatory training on compliance and ethics to all their staff, as required. Record review revealed that five out of seven staff members reviewed did not complete the necessary training for 2023. The staff members identified were Staff D, E, G, H, and I, who were hired on various dates ranging from 2009 to 2022. During an interview with the Regional Nurse, in the presence of the Administrator and Director of Nursing Services, it was confirmed that there was no evidence of completed training for these staff members.
Failure to Provide Behavioral Health Training
Penalty
Summary
The facility failed to provide mandatory behavioral health training to five out of seven staff members reviewed. Specifically, there was no evidence that Staff D, E, G, H, and I completed the required training for 2023. Staff D, a Nursing Assistant (NA), was hired on 9/22/2009; Staff E, a Certified Medication Technician, was hired on 8/18/2009; Staff G, an NA, was hired on 6/12/2022; Staff H, an NA, was hired on 10/6/2016; and Staff I, an NA, was hired on 6/10/2016. During an interview with the Regional Nurse, Administrator, and Director of Nursing Services on 5/6/2024, it was confirmed that the facility could not provide evidence of completed training for these staff members.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to treat two residents with respect and dignity, as observed in video footage and confirmed through staff interviews. Resident ID #2 was seen in a recliner chair wearing only a hospital gown, with their upper thighs and legs exposed while being transported by a Nursing Assistant (NA), Staff D. Staff D did not attempt to cover the resident during the transport. Additionally, Staff D was observed aggressively handling Resident ID #2's arms and pushing a table against the resident's chest, causing the table to be wedged between the resident and a support column. Resident ID #2 has severe cognitive impairment, as indicated by their inability to complete a Brief Interview for Mental Status (BIMS) assessment due to being rarely/never understood. The resident was admitted to the facility in March 2024 with diagnoses including dementia and cognitive communication deficit. Resident ID #7 was observed lying in a recliner chair in the day room, appearing to be in and out of sleep with their head hanging over the side of the chair. This resident also has severe cognitive impairment, as indicated by their inability to complete a BIMS assessment. The resident was readmitted to the facility in February 2024 with diagnoses including dementia, cerebral infarction (stroke), and agitation. Staff interviews revealed that both residents are often left in the day room for extended periods without proper monitoring, especially when staff are on their phones. The facility's Administrator and Director of Nursing Services acknowledged the failure to treat these residents in a dignified manner and in an environment that promotes their quality of life.
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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