Greenwood Operations Dba Greenwood Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Warwick, Rhode Island.
- Location
- 1139 Main Avenue, Warwick, Rhode Island 02886
- CMS Provider Number
- 415008
- Inspections on file
- 28
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 12 (2 serious)
Citation history
Health deficiencies cited at Greenwood Operations Dba Greenwood Center during CMS and state inspections, most recent first.
A resident with a UTI and care plan directives for sepsis screening and reporting of changes in VS and mental status experienced confusion, attempts to get out of bed, removal of nasal cannula, SOB, and decreased O2 saturation during the night shift. The assigned RN increased O2 from 1 L to 4 L but did not notify a provider, document the event, or clearly communicate the change in condition, stating she did not recognize it as a change and did not know the resident’s baseline. On the next shift, another RN found the resident less alert, unable to follow simple commands or form words, with tachycardia and O2 saturation of 93% on 4 L, notified the NP, and, together with the unit manager and another RN, arranged non-medical transport rather than EMS to the hospital. The resident arrived at the hospital via non-medical transport with AMS, SOB, and severe hypoxia, was diagnosed with hypercarbic hypoxic respiratory failure, sepsis, and influenza, and later died. Record review showed no completed competencies for four RNs on identifying changes in condition, and the DON could not provide evidence of education on this topic, while the Medical Director stated he expected decreased O2 saturation to be treated as a change in condition and that EMS should transport residents with such changes.
A resident with a UTI and an order for IV Meropenem every eight hours did not receive three scheduled doses, and there was no evidence the provider was notified of the missed antibiotics. The resident, who was on 1 L O2 via nasal cannula, later exhibited confusion, removal of the nasal cannula, shortness of breath, and decreased O2 saturation requiring an increase to 4 L O2, but the night RN did not document these findings, did not recognize them as a change in condition, and did not notify a provider. Oncoming staff then found the resident with decreased alertness, tachycardia, and continued increased O2 needs, notified the NP, and arranged transfer to the ED via non-medical transport rather than EMS, despite altered mental status and hypoxia. Hospital records documented arrival with altered mental status, severe hypoxia, hypercarbic hypoxic respiratory failure, sepsis, and influenza, and the resident expired later that day; the Medical Director and family interviews confirmed expectations and misunderstandings regarding antibiotic administration, change-in-condition reporting, and the choice of non-medical transport.
Two residents’ rights to dignity, preferences, and privacy were not honored when a NA allegedly provided rude care, failed to follow a dependent resident’s expressed instructions for safe rolling in bed, left the privacy curtain open during personal care, and the resident’s head struck a side rail resulting in a bruise and head pain. In a separate incident, a cognitively intact resident with longstanding anxiety and panic around dogs experienced distress when a visitor’s dog was brought into a common area without prior consent, and the Director of Social Services told the resident to leave the area rather than addressing the resident’s request to remove the dog, contrary to facility policy requiring that patients be asked if they wish to interact with animals.
A resident admitted with a UTI had hospital discharge orders and corresponding facility orders for Meropenem 1 g IV in 50 mL NS three times daily for several days, but three doses were missed. Nursing staff did not administer the antibiotic despite Meropenem and 100 mL NS being available in the IV E‑kit, stating they believed they could not give the medication without a 50 mL NS bag and did not contact the pharmacy for clarification. E‑kit utilization records showed no Meropenem or NS was removed, and documentation did not show that a provider was notified of the missed doses. The resident was later transported to the hospital, where they were found to have hypercarbic hypoxic respiratory failure, sepsis, and influenza, and subsequently died after being placed on comfort measures.
A resident admitted with a UTI and a documented need for 1 L O2 via nasal cannula from the hospital continued to receive oxygen via nasal cannula in the facility without a physician’s order or a care plan addressing oxygen therapy. Progress notes showed ongoing O2 administration, while record review failed to find any corresponding order or care plan. In interviews, an RN and the DON acknowledged that a physician’s order is normally expected for continuous oxygen therapy.
A resident with a complicated UTI had an order for Meropenem 1 gm IV three times daily in normal saline. Although Meropenem and normal saline were listed as available in the IV E-kit, review of the E-kit utilization form showed they were not removed for use, and pharmacy records indicated the medication was not delivered until the following evening. The resident missed three ordered doses, yet the February MAR showed Meropenem as signed out and documented as administered for two of those times when it had not been given. The DON confirmed the medication was not administered until after pharmacy delivery and could not show that the MAR accurately reflected the missed doses.
A resident with multiple medical conditions did not receive any of the 17 ordered doses of Insulin Lispro over several days, as confirmed by MAR review and staff interviews. This omission led to persistently elevated blood glucose levels, clinical decline, and eventual transfer to an acute care hospital. Facility policy required insulin administration as ordered, but no evidence was provided that the medication was given.
Two residents were subjected to physical and verbal abuse by a CNA, including rough handling during care, derogatory comments about weight, and refusal to provide assistance. Multiple staff members witnessed or reported the incidents, and the DON could not provide evidence that the residents were protected from abuse.
Staff failed to promptly remove a CNA who was observed intoxicated and verbally and physically abusive toward two residents, despite multiple reports from other staff. The CNA remained on duty and in the facility for an extended period after the incidents, during which one resident with severe cognitive impairment was handled roughly and insulted, and another resident with intact cognition was verbally abused and denied care.
A resident with insulin-dependent diabetes did not have blood glucose checks performed as ordered by the physician, with documentation showing that the majority of required checks were missed. Nursing staff were unaware of the order, and leadership could not provide evidence that the monitoring was completed.
A resident with insulin-dependent diabetes did not receive prescribed blood sugar monitoring due to a transcription error in the EMR, which caused the order to be entered as an ancillary order rather than a treatment. This led to staff being unaware of the monitoring requirement and resulted in missed blood sugar checks for the majority of the review period.
A medication technician administered Donepezil, Namenda, Senna, and Plavix to a resident who did not have physician orders for these drugs, due to confusion between two roommates. The error was discovered after a nurse realized the medications were given to the wrong individual, and the DON confirmed the administration of unnecessary medications.
The facility failed to adhere to professional standards for food storage and safety, with issues such as grease accumulation, improper labeling, and incorrect food temperatures. Observations revealed non-cleanable surfaces, unlabeled food containers, and expired food items. The Food Service Director acknowledged these deficiencies.
The facility failed to provide newsletters in the primary languages of two residents with limited English proficiency, compromising their right to communication and a dignified existence. Despite care plans indicating language barriers, the residents did not receive the newsletter in a language they could understand, as it was only available in English, Spanish, and French, while their primary languages were Khmer and Mandarin.
The facility failed to ensure that two residents' advance directives were consistent with their EMR. One resident's MOLST form indicated a DNR status, but their profile and care plan listed them as a full code. Another resident's MOLST form indicated a full code, but their physician's order and care plan listed them as DNR. Staff acknowledged the inconsistencies, and the DNS could not explain the discrepancies.
The facility failed to ensure a safe environment by not properly disposing of hazardous materials on the One-North medication cart. Used lancets, a syringe with a needle, and a glass vial were left on top of a biohazardous waste container, accessible to residents. Staff acknowledged the improper disposal, contrary to facility policy requiring immediate disposal in appropriate containers.
The facility failed to provide proper respiratory care for two residents. One resident received 8 liters of oxygen instead of the prescribed 5-7 liters, and the humidifier was not connected, leading to nosebleeds. Another resident received 3 liters of oxygen without a physician's order. Staff acknowledged these discrepancies, and the DON confirmed the need for adherence to prescribed protocols.
A resident with end-stage renal disease on a fluid restriction and renal diet did not receive appropriate care as the facility failed to monitor and document fluid intake and served orange juice, contrary to dietary restrictions. Staff interviews revealed non-compliance with physician orders and facility policies, leading to a deficiency in dialysis care.
A resident with end-stage renal disease was administered Isosorbide Mononitrate despite physician's orders to hold the medication if systolic blood pressure (SBP) was below 120. The medication was given on multiple occasions when the resident's SBP was below this threshold. Interviews with the Nurse Practitioner and the Director of Nursing Services confirmed the oversight, with the latter unable to provide evidence of adherence to the physician's order.
The facility failed to properly store and label medications, as observed in two medication carts and a resident's room. A resident had an opened Lidoderm patch left on their nightstand, contrary to facility practice. Additionally, unlabeled and pre-poured medications were found in medication carts, with staff unaware of their contents or intended recipients.
A resident with dysphagia was given thin liquids instead of the prescribed honey thickened liquids during medication administration, leading to coughing and a change in respiratory status. The RN was unaware of the resident's dietary needs, and the DON expected staff to adhere to diet orders.
The facility failed to adhere to Enhanced Barrier Precautions (EBP) for two residents, one with a suprapubic tube (SPT) and another with a peripherally inserted central catheter (PICC) line. The SPT collection bag was observed on the floor, and hygiene care was provided without a gown. Additionally, a nurse administered IV antibiotics via a PICC line without wearing a gown. These actions were contrary to the facility's infection control policies.
The facility failed to maintain a safe and comfortable environment, affecting several residents. A resident's recliner was in disrepair, another's room had a draft due to missing weather stripping, and two residents had unpainted walls. Maintenance staff were unaware of these issues, and the facility's system for reporting maintenance needs was not effectively utilized.
The facility experienced issues with maintaining safe water temperatures, with readings exceeding the recommended maximum of 120°F in sinks and showers across various units. Staff interviews indicated a lack of awareness regarding appropriate water temperatures, with some relying on hand testing instead of thermometers. Residents expressed concerns about the hot water, and observations confirmed that residents encountered very hot water while using sinks and showers independently. The facility's management attributed the issue to recent water system repairs but could not provide evidence of ensuring a safe environment free from accident hazards.
A resident with hemiplegia, hemiparesis, and type 2 diabetes developed a new Stage 2 pressure ulcer on the coccyx due to inadequate repositioning and delayed pain management. Despite being at risk for pressure ulcers, staff delays in repositioning and inconsistent pain medication administration contributed to the development of the ulcer. Observations and interviews revealed that nursing assistants did not reposition the resident as required, and the resident's pain was not promptly addressed, leading to the deterioration of the resident's condition.
The facility failed to meet professional standards of quality by not having documented protocols for managing a baclofen pump for a resident and by administering diphenhydramine as a scheduled medication instead of as needed for another resident. These deficiencies were confirmed through staff interviews and record reviews.
The facility failed to provide appropriate treatment and services for four residents with indwelling catheters. Care plans required monitoring of urine for sediment, cloudiness, odor, blood, and amount, but there was no evidence that this was consistently performed. Interviews with staff confirmed the lack of consistent monitoring.
The facility failed to maintain an infection prevention and control program for five residents with MDROs. Residents were not on required precautions, and staff did not follow proper hand hygiene and PPE protocols. The DNS confirmed these deficiencies.
The facility failed to maintain a sanitary and comfortable environment in two kitchenettes and two resident rooms. Issues included black matter in ice machines, food debris in kitchen appliances, exposed nails from detached chair rail molding, and unsanitary bathroom conditions. Staff acknowledged these concerns, but they were not addressed during the survey period.
The facility failed to ensure accurate behavioral assessments for two residents, despite documented behaviors in progress notes. The MDS assessments inaccurately reported no behaviors, and the DNS was unable to provide evidence of accurate documentation.
The facility failed to develop and implement baseline care plans within 48 hours of admission for three residents. One resident with dementia exhibited behaviors and rejection of care, another resident with abdominal pain and malaise lacked a transfer status order, and a third resident with a baclofen pump had no care instructions included in the baseline care plan. The DON acknowledged these deficiencies.
The facility failed to provide necessary assistance with ADLs and meals for two residents. One resident, unable to transfer independently, did not receive proper assistance due to a lack of communication among staff. Another resident, requiring one-to-one feeding assistance, was left without help during meals, resulting in untouched and uneaten food.
The facility failed to provide safe and appropriate dialysis care for a resident with end-stage renal disease. Blood pressure measurements were taken on the resident's restricted arm, a sterile dressing was changed without a physician's order, and dialysis recommendations were not communicated to the provider.
A resident with an anxiety disorder received Lorazepam 27 times in March 2024 without evidence of non-pharmacological interventions being attempted first, as required by facility policy. A nurse admitted to administering the medication upon request without following the protocol, and the DON could not provide evidence of compliance.
The facility failed to store and label medications properly. Surveyors found expired Humalog insulin pens, undated Lantus SoloStar insulin pens, and improperly labeled Insulin Lispro vials. Staff acknowledged these deficiencies, and the DON confirmed that facility policy was not followed.
The facility failed to provide or obtain dental services for a resident who lost their dentures before admission. Despite a plan to replace the dentures, no further dental exams or treatments were documented, and the resident struggled to eat without them.
Failure to Ensure RN Competency in Identifying Change in Condition and Appropriate Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff had the competencies and skills to identify and respond to a resident’s change in condition, as required by facility policy and the facility assessment. The facility’s Nursing Services policy required sufficient nursing staff with appropriate competencies to assure patient safety and to identify changes in condition, including use of tools and documentation systems such as Point of Care/PointClickCare to trigger alerts. The facility assessment stated that all staff were educated, trained, and competency-checked on hire and annually, including on practices and tools used to identify resident changes in condition. However, record review showed no evidence that competencies related to identifying a change in condition had been completed for four RNs (Staff B, C, D, and Unit Manager F). The resident involved had been admitted with diagnoses including a urinary tract infection (UTI) and had a care plan that directed staff to screen for sepsis and report a positive screen to a physician, including when two or more criteria such as pulse greater than 100, respiratory rate greater than 20 or oxygen saturation at or below 90%, or altered mental status were present. The care plan also required staff to report to the physician any changes in vital signs and/or condition, including subtle changes. During the 11:00 PM to 7:00 AM shift, RN Staff B found the resident confused, attempting to get out of bed, with the nasal cannula removed, short of breath, and with decreased oxygen saturation. Staff B increased the oxygen flow to 4 L, after which the oxygen saturation improved, but she did not notify a provider, stating she did not consider this a change in condition and was unaware of the resident’s baseline. She reported only that the oncoming nurse should “keep an eye” on the resident and did not document or otherwise communicate in the clinical record that the resident had been without the nasal cannula, required increased oxygen, and was trying to get out of bed unassisted. On the following shift, RN Staff C documented a change from the resident’s baseline, including decreased alertness, inability to follow simple commands or form words, and vital signs showing blood pressure 119/94, heart rate 126, respiratory rate 20, and oxygen saturation 93% on 4 L oxygen. Staff C contacted the nurse practitioner, who ordered the resident sent to the emergency department, and Staff C, along with Unit Manager RN Staff F, RN Staff D, and the nurse practitioner, decided to send the resident via a non-medical transport company rather than emergency medical services. The Continuity of Care Acute Care Transfer Form completed by Staff C indicated the resident was unable to form sentences, required increased oxygen, was unable to follow simple commands, and had a mental status change. Hospital records showed the resident arrived via non-medical transport with altered mental status, shortness of breath, and severe hypoxia, and was diagnosed with hypercarbic hypoxic respiratory failure, sepsis, and influenza, and later expired that day. The Medical Director stated he would expect a decrease in oxygen saturation to be identified as a change in condition with provider notification, and that emergency medical services should transport a resident experiencing a change in condition. The DON was unable to provide evidence that Staff B, C, D, and F had received education on identifying and addressing a resident’s change in condition.
Failure to Administer Ordered IV Antibiotics, Recognize Change in Condition, and Arrange Appropriate Medical Transport
Penalty
Summary
The deficiency involves the facility’s failure to administer ordered IV antibiotics, recognize and document a change in condition, notify a provider of that change, and arrange appropriate medical transport for a resident who was ultimately hospitalized and expired. The resident had been admitted with diagnoses including a UTI and had a care plan intervention to screen for sepsis and report positive screens or changes in vital signs and condition to a physician. A hospital discharge summary ordered Meropenem 1 g IV every eight hours for six days and documented that the resident was alert and oriented and receiving 1 L O2 via nasal cannula. Record review showed that three scheduled doses of Meropenem were not administered as ordered, and there was no evidence that the provider was notified of the missed doses. On one evening, progress notes documented the resident as alert and oriented x3 with O2 saturation at 91% on oxygen via nasal cannula and a pulse of 96. During interview, the RN on the 11 PM–7 AM shift (Staff B) stated she found the resident confused, attempting to get out of bed, with the nasal cannula removed, short of breath, and with decreased O2 saturation. She reported increasing the oxygen flow from 1 L to 4 L, after which the O2 saturation improved, but she did not notify the provider because she did not consider this a change in condition and was unaware of the resident’s baseline. She also stated she told the oncoming nurse to keep an eye on the resident. The clinical record did not contain documentation that the resident had been found without the nasal cannula, that oxygen flow had been increased to maintain saturation, or that the resident was trying to get out of bed unassisted, and there was no documented communication of these findings to oncoming staff. The oncoming RN (Staff C) documented that, later that morning, the resident had a change from baseline with decreased alertness, inability to follow simple commands or form words, and vital signs including BP 119/94, HR 126, RR 20, and O2 saturation 93% on 4 L O2. Staff C contacted the NP, who ordered the resident sent to the ED for evaluation, and transport was arranged with a non-medical transportation company. The Continuity of Care Acute Care Transfer Form completed by Staff C indicated the resident was unable to form sentences, required increased oxygen, was unable to follow simple commands, and was experiencing a mental status change. The NP (Staff E) stated she was notified of the altered mental status and decreased O2 saturation and ordered the transfer but did not assess the resident in person, and she stated she would have expected the resident to be transported per facility policy for such a situation. The DNS reported there was no policy specifying the type of transportation for a resident with a change in condition and that mode of transport was considered a clinical decision. Hospital documentation showed the resident arrived via non-medical transport with altered mental status, shortness of breath, and severe hypoxia, and was found to have hypercarbic hypoxic respiratory failure, sepsis, and influenza, and was transitioned to comfort measures and expired later that day. The Medical Director stated he would have expected IV antibiotics to be administered as ordered or the provider to be notified of missed doses, and that a decrease in O2 saturation should be identified as a change in condition with provider notification. He also stated he would have expected EMS transport for a resident with a change in mental status and decreased O2 saturation and reported being told that the family refused EMS because they wanted a specific hospital. The DNS stated the family member chose non-medical transport after being educated that non-medical transport could not provide medical support, while the family member stated they did not choose the mode of transportation, believed the transporters were EMTs, were not informed that the resident would not be monitored during transport, and were not made aware of the missed antibiotic doses. The facility’s failures included: not administering three ordered doses of IV Meropenem and not notifying the provider of these missed doses; not identifying and documenting the resident’s nighttime confusion, removal of nasal cannula, shortness of breath, decreased O2 saturation, and need for increased oxygen as a change in condition; not notifying the provider at that time; and arranging non-medical rather than emergency medical transport for a resident with altered mental status, increased oxygen needs, and decreased O2 saturation. These failures were cited as placing the resident at risk for serious injury, serious harm, serious impairment, or death and were cross-referenced to F695, F726, F760, and F842.
Failure to Honor Resident Preferences, Privacy, and Anxiety Related to Care and Pet Visits
Penalty
Summary
The deficiency involves the facility’s failure to honor resident rights to dignity, preferences, and privacy during care for two residents. One resident, admitted with muscle weakness and osteoarthritis and care planned as dependent for ADLs including rolling in bed, reported that a nursing assistant was rude, did not follow the resident’s expressed preferences for how to be safely rolled, and refused to close the privacy curtain during care. The resident, who had a BIMS score of 11 indicating moderately impaired cognition but was alert and oriented, stated that because the nursing assistant did not follow the resident’s instructions on how to be turned, the resident’s head struck the bed side rail. The DNS’s assessment documented a faint bruise above the resident’s left eyebrow, approximately the size of a quarter, and the MAR showed the resident received acetaminophen for head pain following the incident. The same incident included a failure to provide privacy during personal care. The resident reported that the nursing assistant refused to close the privacy curtain despite the resident’s roommate needing to walk past the bed to access the bathroom. The roommate confirmed being present in the room, hearing the nursing assistant speak rudely to the resident, hearing the resident yell “ouch,” and observing that the privacy curtain remained open while care was being provided. The facility’s own policy on resident rights requires that each resident be treated with respect and dignity and that resident goals, preferences, and choices be incorporated into care, but the DNS could not provide evidence that these rights were protected and promoted for this resident. A second deficiency involved the facility’s handling of a resident’s anxiety and panic related to dogs in a common area. A cognitively intact resident with a BIMS score of 15 reported having extreme anxiety and panic around dogs since childhood. The resident stated that another resident’s wife brought a dog into a common area without prior notice, which caused the resident to panic, and that when the resident requested removal of the dog, the visitor initially did not remove it. The resident further reported that the Director of Social Services told the resident to leave the common area if uncomfortable with the dog and refused to continue the discussion. In an interview, the Director of Social Services confirmed telling the resident to leave the common area because other residents had the right to enjoy the dogs and acknowledged not allowing the conversation to continue. The DNS stated that if only one resident was uncomfortable with a dog, that resident would be removed rather than the dog, and could not provide evidence that the facility protected and promoted this resident’s rights, despite a facility policy requiring that patients be asked if they would like to visit or interact with animals.
Failure to Administer Ordered IV Antibiotic Resulting in Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when ordered IV antibiotic therapy was not administered as prescribed. The resident was admitted with a diagnosis that included a UTI and had a hospital discharge order for Meropenem 1 g in 50 mL normal saline IV every eight hours for six days. The facility’s physician order reflected Meropenem IV 1 g in 50 mL normal saline three times a day for a complicated UTI through a specified end date. Record review showed the resident missed three doses of the ordered Meropenem IV. The facility had received a complete IV E‑kit that contained Meropenem IV 1 g vials and 100 mL normal saline, and the PharMerica Genesis Master E‑Kit Contents List confirmed these items were available. During interviews, an RN reported she did not administer the antibiotic because it was not available in the exact 50 mL normal saline bag specified, despite knowing Meropenem and 100 mL normal saline were present in the E‑kit. She stated she asked the Unit Manager RN how to administer the medication and was told it could not be given without the correct size saline bag. The pharmacist confirmed Meropenem IV 1 g was available in the E‑kit and stated he would have expected the facility to call the pharmacy to clarify use of the 100 mL normal saline. The IV E‑kit utilization form showed no evidence that Meropenem or normal saline was removed from the kit, and the electronic shipping manifest showed that Meropenem and 50 mL normal saline from the pharmacy did not arrive until later. The DON and Medical Director both acknowledged that Meropenem IV 1 g and 100 mL normal saline were available in the E‑kit and that three doses were missed, and there was no documentation that a provider was notified of the missed doses. The resident was later sent to the hospital after missing three of five doses of the IV antibiotic and was diagnosed there with hypercarbic hypoxic respiratory failure, sepsis, and influenza, and subsequently expired after being transitioned to comfort measures.
Oxygen Therapy Provided Without Physician Order or Care Plan
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice by administering oxygen therapy without a physician’s order or corresponding care plan for a resident who required oxygen. The resident was admitted with a diagnosis that included a UTI, and the hospital discharge summary documented a need for 1 L of oxygen via nasal cannula. Facility progress notes on multiple dates showed the resident was receiving oxygen via nasal cannula, yet record review did not reveal any physician’s order for oxygen therapy or a care plan addressing the resident’s oxygen needs. In interviews, an RN confirmed the resident had been receiving oxygen via nasal cannula since admission and stated that a physician’s order is usually in place when oxygen is required, and the DON similarly stated she would expect a physician’s order for continuous oxygen therapy. This deficiency was cited under the requirement to provide safe and appropriate respiratory care and was cross-referenced to F684.
Incomplete and Inaccurate Documentation of IV Antibiotic Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records related to IV medication administration for a resident admitted with a diagnosis that included a urinary tract infection (UTI). The physician ordered Meropenem 1 gm IV three times a day in 50 mL of normal saline for a complicated UTI, to continue until 2/10/2026. Record review showed that the facility received a complete IV E-kit on 2/4/2026, and the PharMerica Genesis Master E-Kit Contents List indicated that Meropenem 1 gm vials and 100 mL normal saline were available in the IV kit. However, review of the IV E-kit utilization form did not show that Meropenem or normal saline had been removed from the E-kit for administration. Further record review and pharmacy documentation revealed that Meropenem and 50 mL normal saline were not delivered by the pharmacy until the evening of 2/5/2026 at 8:54 PM, and the resident missed three ordered doses of Meropenem IV 1 gm. Despite this, the February 2026 Medication Administration Record (MAR) showed Meropenem IV 1 gm as signed out and documented as administered on 2/4/2025 at 10:00 PM and on 2/5/2025 at 6:00 AM, when it had not actually been given. During an interview, the Director of Nursing Services acknowledged that Meropenem and 100 mL normal saline were available in the E-kit, that the medication was not administered until it was delivered by the pharmacy on 2/5/2026, and that she could not provide evidence that the MAR accurately reflected the three missed doses.
Failure to Administer Prescribed Insulin Resulting in Hospital Transfer
Penalty
Summary
A resident with diagnoses including end stage renal disease and dysphagia was admitted to the facility with a physician's order for Insulin Lispro to be administered subcutaneously three times daily. Review of the Medication Administration Record revealed that the resident did not receive any of the 17 prescribed doses of Insulin Lispro over a six-day period. Staff interviews confirmed that the assigned nurse did not recall administering the medication, and the Director of Nursing Services was unable to provide evidence that the insulin was given as ordered. Facility policy required subcutaneous insulin to be administered safely and accurately according to provider orders. During this period, the resident experienced persistently elevated blood glucose levels, with documented readings significantly above the normal range for diabetics. The resident's condition deteriorated, as evidenced by lethargy, low blood pressure, elevated heart rate, and critically high blood glucose levels, ultimately resulting in transfer to an acute care hospital. The Nurse Practitioner confirmed that staff were expected to follow provider orders for medication administration.
Failure to Prevent Physical and Verbal Abuse of Residents
Penalty
Summary
The facility failed to protect two residents from physical and verbal abuse by a Certified Nursing Assistant (CNA), Staff A. For one resident with severe cognitive impairment and diagnoses including schizophrenia and bipolar disorder, Staff A was witnessed by another CNA and an LPN being rough and aggressive during activities of daily living (ADL) care, including pushing the resident onto their side in a rough manner, causing the resident to cry out in pain and state, 'You're hurting me.' Staff A also made derogatory comments to the resident about their weight. These incidents were observed and reported by staff present during the care. Another resident, with a history of stroke and anxiety and intact cognition, was subjected to verbal abuse by Staff A, who called the resident derogatory names and refused to provide care when requested. Multiple staff, including a CNA, an LPN, and an RN, witnessed or were informed of Staff A's abusive language and refusal to assist the resident. The DON was unable to provide evidence that these residents were kept free from abuse, as required by facility policy and regulations.
Failure to Immediately Remove Abusive and Intoxicated Staff Member
Penalty
Summary
The facility failed to immediately implement effective measures to prevent further potential abuse, neglect, or mistreatment of residents after staff members observed another staff member verbally and physically abusing residents. According to facility policy, any employee suspected of abuse is to be immediately removed from duty pending investigation. However, after multiple staff observed a CNA (Staff A) appearing intoxicated, acting erratically, and being verbally and physically abusive to residents, she was not removed from the unit until near the end of her scheduled shift. Two residents were directly affected by these actions. One resident, with severe cognitive impairment and a history of schizophrenia and bipolar disorder, was observed being handled roughly during ADL care, including being pushed on their side and verbally insulted about their weight. The resident was heard yelling in pain during care. Another resident, with intact cognition and a history of stroke and anxiety, was verbally abused and refused care by the same CNA, who used derogatory language and refused to assist when asked. Despite multiple staff, including a CNA, LPN, and RN, witnessing and reporting Staff A's behavior—such as confusion, intoxication, aggression, and inappropriate comments—Staff A was not immediately removed from the premises. She remained in the facility for over an hour after being told to leave and was only escorted out after the end of her shift. The DON acknowledged that, although staff identified the abuse and intoxication, Staff A was not told to leave immediately, contrary to facility policy.
Failure to Follow Physician's Order for Blood Glucose Monitoring
Penalty
Summary
A deficiency was identified when a resident with type 2 diabetes mellitus and diabetic nephropathy was admitted to the facility with an active physician's order to have blood sugar checked four times daily. Record review showed that this order, which was also reflected in the resident's care plan, was not followed. Specifically, between the admission date and the date of the survey, there was no evidence that the resident's blood sugar was checked as ordered, with 137 out of 152 opportunities missed according to the electronic medical record (EMR). During interviews, a registered nurse confirmed that blood sugar checks would be documented in the EMR and acknowledged being unaware of the physician's order. The Director of Nursing Services was unable to provide evidence that the order had been followed, and the nurse practitioner stated it was her expectation that the physician's order would have been carried out. No documentation was found to support that the required blood glucose monitoring was performed as directed.
Failure to Accurately Transcribe and Implement Blood Sugar Monitoring Orders
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus and diabetic nephropathy was admitted with a physician's order to have blood sugar checked four times daily. The resident's care plan also indicated the need for regular blood glucose monitoring as ordered. However, record review showed that blood sugar checks were not performed as ordered, with documentation missing for 137 out of 152 opportunities during the review period. Further investigation revealed that the order for blood sugar monitoring was incorrectly transcribed into the electronic medical record (EMR) as an ancillary order rather than a treatment. As a result, the order did not populate on the resident's Treatment Administration Record, and nursing staff were unaware of the requirement to monitor the resident's blood sugar as prescribed. Both the registered nurse and the Director of Nursing Services confirmed the transcription error and the resulting lack of monitoring.
Medication Administration Error Resulting in Unnecessary Drug Administration
Penalty
Summary
A deficiency occurred when a medication technician administered medications to a resident that were prescribed for the resident's roommate. The medications given in error included Donepezil, Namenda, Senna, and Plavix, none of which were ordered for the resident who received them. The resident who received the medications had a history of chronic kidney disease stage 3, anemia, essential hypertension, and unspecified dementia with anxiety, and was noted to have severe cognitive impairment based on a recent assessment. Review of the medication administration records confirmed that these medications were not prescribed for the resident who received them, but were instead prescribed for the roommate. The incident was discovered after a registered nurse realized that the medications intended for the resident in the bed by the window were instead given to the resident in the bed by the door. The nurse had handed the medication cup to the technician with instructions, but the technician administered the medications to the wrong resident. The Director of Nursing acknowledged that the resident had received unnecessary medications as a result of this error.
Deficiencies in Food Storage and Safety Practices
Penalty
Summary
The facility was found to have several deficiencies related to food storage, preparation, and service during a survey. Observations in the main kitchen revealed grease accumulation on the hood over the stove, an ice machine dispenser cover held with non-cleanable black masking tape, and a utility cart with a wooden handle that could not be sanitized. Additionally, ten food meal delivery carts had grease and grime accumulation. The cold holding temperatures of food items such as Italian Sub Sandwiches and coleslaw were above the acceptable limit of 41 degrees Fahrenheit, with readings of 48 and 45 degrees Fahrenheit, respectively. The Food Service Director acknowledged these temperature discrepancies. Further observations showed that the ice machine had an accumulation of black particles, and several containers in the walk-in refrigerator lacked proper food identifiers. Sixty Vital Cuisine Mighty Shakes were found without a use-by date, and a container of egg salad was labeled with incorrect dates. The Food Service Director admitted that the food items were beyond their use-by dates and lacked proper labeling, and acknowledged the need for cleaning the hood, ice chute, and food delivery carts.
Failure to Provide Linguistic Support for Non-English Speaking Residents
Penalty
Summary
The facility failed to ensure that residents with limited English proficiency received communication in a language they understand, compromising their right to a dignified existence and self-determination. Resident ID #16, who was admitted with dementia and resides on the second floor, East Unit, had a care plan indicating impaired communication due to a language barrier, but it did not specify the resident's primary language. During a survey, it was observed that the resident did not receive the facility's newsletter, 'THE DAILY CHRONICLE,' in a language they could understand, as it was only available in English, Spanish, and French, while the resident's primary language was Khmer. Similarly, Resident ID #52, also residing on the second floor, East Unit, with a diagnosis including dementia, had a care plan noting their primary language as Chinese. The resident did not receive the newsletter in a language they could comprehend, as confirmed by their representative, who stated that the resident speaks Mandarin. The Director of Nursing Services acknowledged that these residents sometimes received the newsletter in English, which they could not fully understand. This failure to provide linguistic support as outlined in the facility's assessment document led to the deficiency identified by the surveyors.
Inconsistencies in Advance Directives and EMR
Penalty
Summary
The facility failed to ensure that residents' advance directives were consistent with their electronic medical records (EMR) for two residents. Resident ID #16 was readmitted with a diagnosis including acute respiratory failure. The Medical Orders for Life Sustaining Treatment (MOLST) form indicated a Do Not Attempt Resuscitation (DNR) status, but the Clinical Resident Profile and care plan listed the resident as a full code, meaning CPR should be performed. A registered nurse confirmed the inconsistency and stated that in an emergency, the resident would be treated as a full code. Resident ID #154, admitted with a diagnosis including acute respiratory failure, had a MOLST form signed indicating a desire for resuscitation (full code). However, a physician's order and care plan listed the resident as DNR. There was no evidence that the resident had changed their code status to DNR after signing the MOLST form. The nurse practitioner who signed the MOLST form acknowledged the inconsistency, and the Director of Nursing Services was unable to provide evidence explaining the discrepancies in the residents' records.
Improper Disposal of Hazardous Materials on Medication Cart
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards by not properly disposing of hazardous materials on the One-North medication cart. During a surveyor observation, it was noted that used lancets and a glass vial were left on the top surface of a biohazardous waste container, making them visible and accessible to residents. This was observed twice, with the first instance involving two used lancets and a glass vial, and the second instance involving three used lancets, a used syringe with a needle attached, and a glass vial. During these observations, no staff were present at or near the medication cart, while multiple residents were in proximity. The Registered Nurse, Staff D, acknowledged the presence of the hazardous materials on the biohazardous waste container and confirmed that they were not disposed of appropriately. The Director of Nursing Services also indicated that all sharps materials should be disposed of within the biohazardous waste container, not on its top surface. The facility's policy on needle handling and sharps injury prevention requires contaminated sharps to be discarded immediately in appropriate disposal containers, which was not adhered to in this instance.
Failure to Adhere to Oxygen Therapy Protocols
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents. Resident ID #24, who was admitted with emphysema, had a physician's order for oxygen administration at 5-7 liters per minute via nasal cannula. However, observations revealed the resident was receiving 8 liters of oxygen, exceeding the prescribed amount. Additionally, the oxygen tubing was not connected to the humidifier bottle, which is required for flows greater than or equal to four liters. The resident reported not adjusting the oxygen flow themselves and acknowledged the absence of the humidifier, which was associated with nosebleeds. The Director of Nursing Services confirmed the expectation for the resident to receive the ordered oxygen flow. Resident ID #154, admitted with chronic obstructive pulmonary disease, was observed receiving 3 liters of oxygen via nasal cannula without a physician's order, contrary to facility policy. Staff acknowledged the absence of a physician's order for the oxygen being administered. The Director of Nursing Services indicated that staff should have obtained a physician's order for the oxygen administration. These deficiencies highlight a failure to adhere to prescribed oxygen therapy protocols and facility policies, potentially impacting resident safety and care quality.
Failure to Monitor Fluid Intake and Adhere to Renal Diet for Dialysis Resident
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident with end-stage renal disease who was on a fluid restriction and renal diet. The resident, who was cognitively intact, had a physician's order for a daily fluid restriction of 1000 milliliters and was to receive outpatient dialysis three times a week. However, the facility did not monitor or document the resident's fluid intake over a 24-hour period as required by their policy. Additionally, the resident was served orange juice, which is not recommended for individuals on a renal diet, and there was no documentation or explanation for this dietary oversight. Interviews with staff, including a registered nurse and the Director of Nursing Services, revealed a lack of adherence to the physician's orders and facility policies regarding fluid monitoring and dietary restrictions. The registered nurse admitted to only documenting fluids she provided, not the total fluid intake, and the Director of Nursing Services could not provide evidence of proper monitoring. The registered dietitian also acknowledged the error in serving orange juice to the resident, indicating a failure to follow the renal diet requirements. These actions and inactions led to the deficiency in providing safe and appropriate dialysis care for the resident.
Failure to Adhere to Medication Parameters for a Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically regarding the administration of Isosorbide Mononitrate. The resident, who was admitted with end-stage renal disease and dependent on renal dialysis, had a physician's order to hold the medication if the systolic blood pressure (SBP) was less than 120. However, the medication was administered on multiple occasions when the resident's SBP was below this threshold, as documented in the February and March 2025 Medication Administration Records. Interviews with the Nurse Practitioner and the Director of Nursing Services confirmed the oversight. The Nurse Practitioner acknowledged that the medication should have been held on the specified dates when the SBP was lower than 120, as per the physician's order. The Director of Nursing Services was unable to provide evidence that the staff adhered to the physician's order, indicating a lapse in following the prescribed medication parameters for the resident.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and label drugs and biologicals according to professional standards, as observed in two medication carts and a resident's room. Resident ID #99, who was admitted with a displaced intertrochanteric fracture of the left femur and pain in the left hip, had an opened Lidoderm patch left on their nightstand on multiple occasions. The resident, with intact cognition, indicated that the patch was left by a staff member. The Director of Nursing Services (DNS) confirmed that it is not the facility's practice to leave medications at a resident's bedside, and no evidence was provided to explain why the patch was left there. Additionally, during observations of the medication carts, a clear medication cup without labels containing two orange tablets was found, and another cup labeled '23' with a white tablet was discovered. Staff D admitted to pre-pouring the medication, which is against the facility's policy, and was unaware of the contents or intended recipient of the labeled cup. The DNS stated that staff are expected not to pre-pour medications and should administer them at the time they are prepared.
Failure to Provide Honey Thickened Liquids to Resident with Dysphagia
Penalty
Summary
The facility failed to provide food and drink in a form designed to meet the individual needs of a resident with dysphagia and a requirement for honey thickened liquids. During a surveyor observation, a registered nurse administered liquid medications to the resident and provided them with a cup of clear, thin liquid, which was not in accordance with the prescribed honey thick consistency. The resident, who has a history of difficulty swallowing and aspiration of fluid, began to cough after consuming the thin liquid, indicating a potential risk to their health. The resident's care plan clearly indicated the need for honey thickened liquids due to their swallowing difficulties, and this requirement was not adhered to during the medication administration. The registered nurse admitted to being unaware of the resident's prescribed diet and acknowledged the error after reviewing the resident's records. The Director of Nursing Services expressed that staff are expected to follow diet orders and check them prior to administering food or drinks, highlighting a lapse in protocol adherence in this instance.
Infection Control Deficiencies in EBP for Residents with SPT and PICC Line
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for two residents. Resident ID #37, who has a suprapubic tube (SPT), was observed with the SPT collection bag resting on the floor multiple times, contrary to the facility's policy that requires the bag to be kept off the floor. Additionally, a nursing assistant was observed providing hygiene care to this resident without wearing a gown, despite being aware of the requirement to do so under EBP. The Director of Nursing Services (DNS) confirmed that staff should have worn a gown and that the SPT collection bag should not have been on the floor. Resident ID #51, who has a peripherally inserted central catheter (PICC) line, was also not provided care in accordance with EBP. During a medication administration task, a registered nurse accessed the resident's PICC line and began infusing an IV antibiotic without wearing a gown, acknowledging afterward that a gown was required. The DNS stated that she expected the nurse to wear a gown when administering IV antibiotics via a PICC line for a resident on EBP. These observations indicate a failure to adhere to the facility's infection control policies, potentially increasing the risk of infection transmission.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, functional, and comfortable environment for residents, staff, and the public, as observed in two of the six units. Resident ID #14, who has intact cognition and prefers to sleep in a recliner, was found with a recliner in disrepair, with torn upholstery exposing foam cushioning. The resident reported that the recliner had been in this condition for several weeks, and the facility was aware, yet no action had been taken to repair or replace it. Maintenance staff acknowledged the issue but were unaware of the recliner's condition until the surveyor's observation. Resident ID #79, diagnosed with an anxiety disorder, reported a draft in their room due to missing weather stripping on the window, making the room colder when windy. The resident stated that the window had been in this condition since their admission, and the facility was aware. Maintenance staff confirmed the need for weather stripping but were unaware of the issue until the surveyor's observation. Residents ID #73 and #70 both had large, unpainted areas on their walls, with Resident ID #70's wall also having several gouges. These conditions had persisted for months, with staff acknowledging the issues but failing to address them. The facility's maintenance system, Tels, was not utilized effectively to communicate these maintenance needs, leading to prolonged discomfort for the residents. The Administrator could not provide evidence of maintaining a safe and comfortable environment for the affected residents.
Water Temperature Safety Concerns in Multiple Units
Penalty
Summary
The facility failed to ensure safe water temperatures in multiple areas, as observed during surveys on various units. Water temperatures exceeding the recommended maximum of 120 degrees Fahrenheit were recorded in sinks and showers across different units on multiple occasions. Staff interviews revealed a lack of awareness regarding appropriate water temperatures, with some staff members relying on hand testing rather than using thermometers. Residents also expressed concerns about the hot water, with one resident mentioning the need to mix hot water with cold water to prevent burns. The deficiency in maintaining safe water temperatures posed a significant risk to residents, potentially leading to serious harm, impairment, or even death. Despite documentation indicating that residents were independent in bathing and did not require staff assistance, observations revealed residents experiencing very hot water temperatures while using sinks and showers independently. The facility's management acknowledged the issue, attributing it to recent water system repairs, but was unable to provide evidence of ensuring a safe environment free from accident hazards.
Failure to Address Pressure Ulcer Prevention and Pain Management
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing. The resident, identified as Resident ID #33, was admitted with diagnoses including hemiplegia, hemiparesis, and type 2 diabetes. Despite being at risk for pressure ulcers, the resident experienced a new Stage 2 pressure ulcer on the coccyx area, as noted in a Skin Check. The resident reported pain and requested repositioning, but staff delays and inadequate attention to the resident's needs resulted in the development of an open area on the coccyx. During surveyor observations and interviews, it was revealed that staff members failed to promptly address the resident's pain and repositioning needs. Nursing Assistants were observed not repositioning the resident as required, leading to the discovery of the new pressure ulcer. The resident's pain was not adequately managed, with delayed administration of pain medication and inconsistent monitoring of the wound. Despite the resident's complaints and requests for assistance, staff members did not take timely action to prevent the development of new pressure ulcers. The facility's lack of timely response to the resident's pain and repositioning needs, as well as the failure to identify and address the new pressure ulcer promptly, contributed to the deficiency in providing necessary care to prevent pressure ulcers. Staff members acknowledged the new open area, but delays in repositioning and inadequate pain management were evident. The resident's condition deteriorated due to the facility's failure to adhere to professional standards of practice in preventing and treating pressure ulcers.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality in two instances. First, for a resident with a SynchrinMed II Drug Infusion Pump, the facility did not have documented physician orders or protocols for managing the pump, including refill schedules, monitoring for alarms, and recognizing symptoms of baclofen withdrawal. This oversight was confirmed during interviews with both a registered nurse and the Director of Nursing Services, who were unaware of the necessary procedures for managing the baclofen pump. Second, another resident was administered diphenhydramine 25 mg as a scheduled medication instead of as needed, as per the physician's order. This error resulted in the resident receiving 97 doses of the medication over a period of time. The Director of Nursing Services acknowledged that the facility failed to follow the physician's order, which was brought to their attention by a surveyor.
Failure to Monitor Urine Output and Condition for Residents with Catheters
Penalty
Summary
The facility failed to provide appropriate treatment and services for four residents with indwelling catheters. Resident ID #1, who was readmitted with obstructive and reflux uropathy, chronic kidney disease stage 3, and acute kidney failure, had a care plan that required monitoring of urine for sediment, cloudiness, odor, blood, and amount. However, there was no evidence that this monitoring was consistently performed. Similarly, Resident ID #25, with a supra pubic catheter and neuromuscular dysfunction of the bladder, had a care plan that included monitoring urine for the same parameters, but the facility failed to provide evidence that this was done consistently. Interviews with staff confirmed the lack of consistent monitoring for both residents. Resident ID #69, admitted with heart failure, required an indwelling foley catheter due to wounds affected by incontinence. The care plan specified monitoring the amount of urine, but there was no evidence that this was consistently done. Additionally, Resident ID #104, admitted with hydronephrosis, dependence on renal dialysis, and chronic kidney disease stage 4, required monitoring and recording of urine output from an indwelling foley catheter. The facility failed to provide evidence that this monitoring was consistently performed. Interviews with the Director of Nursing Services confirmed the lack of consistent monitoring for these residents as well.
Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an infection prevention and control program to prevent the transmission of communicable diseases and infections for five residents with Multidrug Resistant Organisms (MDRO). Resident ID #1, who was readmitted with diagnoses including retention of urine and benign prostatic hyperplasia, was positive for MRSA, VRE, and ESBL. Despite requiring isolation precautions, surveyor observations revealed that the resident was not on any precautions. Similarly, Resident ID #77, readmitted with anemia and gastrointestinal hemorrhage, was positive for MRSA and VRE but was not on any precautions. Resident ID #105, with a diagnosis of colon cancer, was positive for MRSA and also not on any precautions as observed by the surveyors. The Infection Preventionist and Director of Nursing Services (DNS) confirmed that these residents should have been on enhanced barrier precautions due to their MDRO diagnoses. The facility's policy on Clostridioides difficile infection was not followed for Resident ID #318, who was admitted with enterocolitis due to C-Diff. A Registered Nurse was observed using alcohol-based hand rub instead of washing hands with soap and water after removing her gown and gloves, which is against the facility's policy for C-Diff precautions. The nurse acknowledged the mistake, and the DNS confirmed that hand washing with soap and water is expected for C-Diff precautions. Additionally, the facility's policy on contact precautions was not adhered to for Resident ID #372, who was admitted with MRSA. A Physical Therapist Assistant and a Nursing Assistant were observed removing their personal protective equipment (PPE) outside the resident's room and failing to perform proper hand hygiene. The Nursing Assistant further failed to remove gloves and perform hand hygiene after exiting the resident's room and entered another resident's room with the same gloves. Both staff members acknowledged their actions, and the DNS confirmed that proper PPE removal and hand hygiene were expected. The DNS was unable to provide evidence that the facility maintained an effective infection prevention and control program.
Sanitation and Maintenance Deficiencies in Kitchenettes and Resident Rooms
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment in two kitchenettes and two resident rooms. Observations in the 1st floor kitchenette revealed black matter in the ice machine, pink film along the water trough, and food debris in the microwave and toaster oven. The 2nd floor kitchenette had an incorrectly routed drainage hose causing stagnant water and black matter buildup, along with food debris in the toaster oven. The District Manager acknowledged these issues but could not provide evidence of maintaining a sanitary environment. In the South Unit, a resident's room had a chair rail molding pulled away from the wall, exposing nails. The Acting Maintenance Director confirmed the issue and removed the molding and nails. In the East Unit, a resident's bathroom had black and brown matter on the walls, detached baseboard molding, and bubbling paint. A housekeeper confirmed the bathroom had been in this condition for at least a month, and the Acting Maintenance Director acknowledged these concerns. These environmental issues were not addressed during the survey period despite being reported by staff.
Inaccurate Behavioral Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the assessment accurately reflected the residents' status for two residents reviewed for behavioral assessments. Resident ID #109 was readmitted with diagnoses including dementia and anxiety disorder. Despite multiple progress notes documenting verbal and combative behaviors, the Comprehensive Minimum Data Set (MDS) assessment inaccurately reported no behaviors. The Director of Nursing Services (DNS) was unable to provide evidence that the MDS assessment for Resident ID #109 was completed accurately, specific to his/her behaviors. Resident ID #113 was readmitted with diagnoses including dementia and anxiety disorder. Progress notes documented daily physical and verbal behaviors, rejection of care, and wandering. The resident was also noted to be experiencing hallucinations, delusions, and psychosis, including attempts to elope from the facility. Despite these documented behaviors, the discharge MDS assessment inaccurately reported no behaviors. The DNS acknowledged that the MDS assessment for Resident ID #113 was not documented accurately to reflect the resident's status. The inaccuracies in the MDS assessments for both residents indicate a failure by the facility to ensure that the assessments accurately reflected the residents' behavioral status. This deficiency was identified through record reviews and staff interviews, highlighting discrepancies between documented behaviors in progress notes and the MDS assessments.
Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan for each resident within 48 hours of admission, as required by the State Operations Manual, Appendix PP- Guidance to Surveyors for Long Term Care Facilities. This deficiency was identified for three newly admitted residents. Resident ID #109, admitted for short-term rehabilitation with a diagnosis of dementia with moderate agitation, exhibited verbal and physical behaviors and rejection of care, medications, and treatments. There was no evidence of a baseline care plan addressing these behaviors or the resident's discharge planning goals within 48 hours of admission. Resident ID #366, admitted with diagnoses including abdominal pain and malaise, expressed a desire for a shower and an inability to get out of bed independently. However, there was no physician's order for the resident's transfer status, and no baseline care plan was developed to address the resident's decreased ability to perform activities of daily living. Resident ID #317, admitted with complex regional pain syndrome and other conditions, had an intrathecal baclofen pump placed prior to admission. The facility failed to include instructions for the care of the baclofen pump in the baseline care plan. The Director of Nursing Services acknowledged the absence of baseline care plans for these residents within the required timeframe.
Failure to Provide Necessary Assistance with ADLs and Meals
Penalty
Summary
The facility failed to provide necessary services to a resident who was unable to perform activities of daily living (ADLs). Resident ID #366, admitted with diagnoses including anemia and malaise, had a care plan indicating a risk for decreased ability to perform ADLs due to recent hospitalization. However, the care plan did not specify the level of assistance required for transfers, and staff were unaware of the resident's needs. The resident reported being unable to get out of bed independently and not being regularly assisted by staff. Interviews with nursing assistants and licensed practical nurses revealed a lack of communication and understanding regarding the resident's transfer needs, with some staff believing that therapy was responsible for transfers. The Director of Rehabilitation indicated that the resident required a Hoyer lift for transfers, but this information was not communicated to nursing staff, leading to inadequate care and assistance for the resident's transfers. The facility also failed to provide necessary assistance with meals for Resident ID #88, who was admitted with diagnoses including dysphagia and aphasia following a stroke. The resident's care plan indicated a need for one-to-one feeding assistance due to severe cognitive impairment and nutritional risk. However, during surveyor observations, the resident's meal trays were left untouched on a dresser across the room, and staff did not assist the resident with eating. Nursing assistants and licensed practical nurses acknowledged that the resident required assistance with meals but failed to provide it, leaving the resident's meals uncovered and uneaten. The Director of Nursing Services confirmed that the resident required one-to-one feeding assistance and that staff were expected to physically assist and cue the resident during meals. These deficiencies highlight a lack of communication and coordination among staff regarding the care needs of residents, leading to inadequate assistance with transfers and meals. The failure to provide necessary services and assistance to residents with specific needs resulted in unmet care requirements and potential harm to the residents involved.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care consistent with professional standards of practice. The resident, who has end-stage renal disease and uses a central venous catheter for hemodialysis, had a physician's order to avoid blood pressure measurements on the left arm. However, blood pressure measurements were taken on the left arm on multiple occasions. Additionally, a sterile dressing over the dialysis site was changed by a nurse without obtaining the required physician's order. Furthermore, dialysis recommendations, including medication adjustments, were not communicated to the provider as required by the plan of care. The deficiencies were identified through record reviews and staff interviews. The Director of Nursing Services acknowledged that the facility did not follow the physician's order regarding blood pressure measurements, failed to obtain an order before changing the sterile dressing, and did not communicate dialysis recommendations to the provider. These actions and inactions led to the facility's failure to provide safe and appropriate dialysis care for the resident.
Failure to Implement Non-Pharmacological Interventions Before Administering Psychotropic Medication
Penalty
Summary
The facility failed to ensure a resident's drug regimen was free from unnecessary psychotropic drugs. The resident, admitted in February 2016 with a diagnosis of anxiety disorder, had an order dated June 26, 2019, specifying that non-pharmacological interventions should be used before administering PRN anti-anxiety medications. Despite this, the resident received Lorazepam 27 times between March 1, 2024, and March 20, 2024, without evidence that any non-pharmacological interventions were attempted prior to administering the medication. During interviews, a Registered Nurse admitted to giving the medication upon the resident's request without implementing the ordered non-pharmacological interventions. The Director of Nursing Services was unable to provide evidence that the facility's policy and orders were followed, confirming the deficiency in adhering to the prescribed protocol for psychotropic medication use.
Failure to Properly Store and Label Medications
Penalty
Summary
The facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles. Specifically, surveyor observations revealed that the first-floor South Unit medication storage room contained three expired Humalog insulin pens. Additionally, the 2nd floor East Unit medication cart had two Lantus SoloStar insulin pens that were opened and in use but not dated, contrary to the manufacturer's instructions to discard the medication 28 days after opening. Staff acknowledged these deficiencies during interviews with the surveyors. Further deficiencies were observed on the 2nd floor North Unit medication cart, where two multi-dose vials of Insulin Lispro were found. One vial was opened and not dated, while the other had an illegible date. Additionally, a Lantus kwik pen was found with a room number written in marker but no resident identifier, and the date was illegible. Staff were unable to determine the dates when the vials were opened or identify the resident for the Lantus kwik pen. The Director of Nursing Services confirmed that the facility policy was not followed and acknowledged the need for proper labeling and discarding of medications per manufacturer's instructions.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide or obtain dental services for a resident who was admitted in May 2021 with a diagnosis including dysphagia. The resident had moderately impaired cognition and was on a regular textured diet. During an interview, the resident's family member indicated that the resident had difficulty eating hard foods because they did not have dentures, which were lost at the hospital before admission to the facility. The resident expressed a desire for dentures and concern about going without them for so long. An observation confirmed the resident's difficulty eating without dentures. A document from HealthDrive Dental Group dated April 2022 indicated a plan to replace the lost dentures, but there was no evidence of further dental exams or treatments after that date. The Director of Nursing Services could not provide evidence that the resident received routine dental services or that the dentures were replaced as planned.
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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