Adviniacare Waterview Villas, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in East Providence, Rhode Island.
- Location
- 1275 South Broadway, East Providence, Rhode Island 02914
- CMS Provider Number
- 415042
- Inspections on file
- 32
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Adviniacare Waterview Villas, Llc during CMS and state inspections, most recent first.
Improper storage of drugs and biologicals was found on 3 of 6 med carts observed. Surveyors found an opened, undated Lidocaine injection, Erythromycin that should have been discarded, a nasal spray without a resident name, a Ceftriaxone vial with a partially torn label, and multiple Ertapenem vials for discharged residents. Staff and the DON acknowledged that several of the medications were expired, discontinued, or otherwise not properly labeled and should have been discarded.
Two residents had incomplete medical records related to outpatient specialist visits. One resident with heart failure and a recent fall had a general surgery follow-up that was canceled and rescheduled, but the COC was missing and later appointments were not documented as completed; the scheduler was unaware of the follow-up visits and transport was not arranged. Another resident with a failed hip arthroplasty returned from an ortho visit with instructions for dental clearance, bone health evaluation, bone density testing, and cardiac clearance, but the COC was not in the chart and the instructions were not shown as reviewed or implemented. The DON/DNS could not produce the missing records and cited delayed scanning.
Failure to Reweigh and Report Significant Weight Loss: A resident with fractured hip and dysphagia had severe weight loss and additional significant weight changes, but nursing did not obtain required reweighs to confirm the measurements. The RD was also not notified promptly of the major weight loss, and the DON acknowledged the missed reweighs and delayed notification.
Facility assessment lacked input from resident representatives and family members. Record review of the facility's assessment document did not show evidence of a plan that included involvement from residents' families or representatives, and the DON acknowledged that the assessment did not include that input.
A resident with RLS and seizures, who was cognitively intact, had a physician’s order for pramipexole twice daily that was not followed when nine doses were missed over several days because the medication was unavailable. The MAR documented multiple omitted morning and afternoon doses, and the resident reported going several days without the drug, experiencing leg discomfort, pain radiating to the back, and pacing due to inability to sit still. A provider note indicated the pharmacy failed to deliver the medication and that the resident requested ED transfer to obtain it. The DON acknowledged the medication was not given as ordered due to unavailability, and the pharmacy account manager reported that the facility did not submit the refill request until several days after doses began to be missed.
A resident with dementia and a history of colon cancer experienced worsening genital lesions and a herpes simplex outbreak. The facility failed to complete an ordered genital swab, delayed reporting a positive UTI result to the provider, and did not notify the responsible party of changes in condition or new medications. Staff interviews confirmed lapses in following up on diagnostic tests and communicating with the family, resulting in delayed treatment and more invasive interventions.
A resident with dementia and a history of falls experienced a significant decline after staff failed to update the care plan and implement recommended bed rail safety measures. Despite a physical therapy recommendation and physician order for side rails to assist with bed mobility, there was a delay in installation, and the resident fell out of bed, sustaining fractures that required surgery. Staff interviews confirmed the absence of side rails at the time of the fall and delays in pain management and diagnostic evaluation.
Garbage bags were left outside the dumpster and accumulated in the parking lot after the waste management company placed a hold on trash removal services due to nonpayment. This resulted in improper disposal of refuse, as confirmed by photographic evidence and staff interviews, and was reported to the Department of Health for attracting pests and creating a risk of disease.
A resident with significant medical needs, documented as requiring two staff for bed mobility and hygiene, was assisted by only one nursing assistant during care. The staff member, unaware of the two-person requirement, performed a bed bath alone, leading to the resident falling from bed and sustaining injuries that required hospital transfer. The DON did not acknowledge the documented two-person assistance requirement.
The facility failed to provide necessary ROM and mobility services to residents with contractures and limited mobility. A resident with anoxic brain damage had a contracted hand without interventions, while another with spinal stenosis had bilateral hand contractures and limited ROM, yet received no therapy. Additionally, a resident admitted for respite care was not provided with a wheelchair or therapy screen, remaining bedbound despite expressing a desire to get out of bed.
A resident admitted for respite care with reduced mobility and a history of poliomyelitis developed a pressure ulcer due to the facility's failure to provide necessary treatment and services. Despite the resident's intact cognition and desire to be out of bed, staff did not transfer the resident for 15 days, leading to a facility-acquired wound. The resident's wound care was inadequately managed, and new pressure areas were identified, indicating the development of pressure ulcers.
The facility was cited for deficiencies in food safety and storage practices. Surveyors observed grease accumulation on kitchen equipment and improper storage of farm eggs brought by a staff member, violating the Rhode Island Food Code. The administrator acknowledged the need for cleaning and proper food sourcing.
The facility failed to adhere to physician's orders for several residents, including medication refusals for a resident with Parkinson's and hypertension, improper use of straws for a resident with dysphagia, unreported high blood sugar levels for a diabetic resident, and delayed wound dressing changes. These issues were acknowledged by the DNS and staff, highlighting lapses in communication and adherence to care protocols.
A facility failed to monitor a resident with a history of mental disorders and suicidal ideations, as required for their mental and psychosocial well-being. Despite recommendations for monitoring, the care plan and records lacked interventions for suicidal ideation. Staff interviews confirmed the absence of monitoring, highlighting a deficiency in providing necessary behavioral health care.
A resident with mild communication deficit and major depressive disorder was not provided with an activity program aligned with their preferences, as documented in their care plan. Despite the resident's expressed interest in reading, music, and group activities, they were observed alone in their room without engagement. Staff interviews revealed that the activities department failed to visit the resident, and Nursing Assistants did not facilitate activities as expected.
Two residents experienced significant weight loss due to the facility's failure to adhere to its policies on monitoring and addressing nutritional status. One resident with dementia and dysphagia lost 8 pounds in two weeks without proper re-weighing or intervention, while another resident with poliomyelitis and depression lost 1.3 pounds in 10 days without a nutritional care plan or assessment. The facility did not notify the interdisciplinary team or implement necessary interventions, leading to deficiencies in maintaining residents' nutritional health.
The facility failed to secure medication storage as required, with keys to medication carts and storage rooms being shared among staff, including non-licensed personnel, due to the bathroom key being on the same key ring. This breach was confirmed by staff interviews and acknowledged by the DON.
The facility failed to follow physician's orders and maintain accurate records for several residents. A resident with vascular dementia did not have their heels offloaded or heel protectors applied as ordered, and the TAR inaccurately showed completion. Another resident with muscle weakness also did not have their heels offloaded as required. Additionally, a resident with poliomyelitis did not receive a timely wound dressing change, despite the TAR indicating it was done. These deficiencies were acknowledged by nursing staff and the DON.
The facility failed to properly disinfect a glucometer used for multiple residents, contrary to both facility policy and manufacturer guidelines. A resident with type 2 diabetes mellitus had their blood sugar checked by a nurse who did not clean the glucometer before or after use. The Director of Nursing confirmed the expectation for proper disinfection, which was not met.
The facility did not notify residents receiving Medicaid benefits when their personal needs account balance approached the SSI resource limit, risking their Medicaid eligibility. This was identified for four residents with balances over $4,000, and the Account Receivable Assistant could not provide evidence of required notifications.
The facility failed to conduct weekly skin audits as per physician's orders for three residents, including those with severe protein calorie malnutrition and Alzheimer's disease. The audits were not performed for several weeks, and the DON could not provide evidence of compliance.
The facility failed to monitor and maintain the nutritional status of two residents. One resident was not consistently weighed on the same scale, and meal intakes were not recorded. Another resident, diagnosed with severe protein calorie malnutrition, was not weighed for a month, and meal intakes were frequently unrecorded. The resident also refused a nutritional supplement, but the provider was not notified. The DON could not provide evidence of proper monitoring or communication.
Improper Storage of Medications on Multiple Medication Carts
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles on 3 of 6 medication carts observed. During observation of the second-floor medication cart side A, surveyors found an opened, undated 20 mL bottle of Lidocaine injection, an opened tube of Erythromycin 0.5% that was dated but had an expiration date listed, and an opened bottle of nasal moisturizing spray with no resident name identifier. Staff acknowledged that the Lidocaine was opened and undated, the nasal spray should have had a resident name identifier, and the Erythromycin should have been discarded. On the second-floor nurse side A cart, surveyors also found a 1-gram vial of Ceftriaxone with the prescription label partially torn off, along with four 1-gram bottles of Ertapenem for two discharged residents. Staff acknowledged that the Ceftriaxone label did not identify the resident for whom it was prescribed and should have been discarded, and that the Ertapenem for discharged residents should have been discarded. On the third-floor medication cart side A, surveyors found another 1-gram vial of Ertapenem for a discharged resident, and the LPN acknowledged it should have been discarded. The DON stated it was her expectation that nursing staff would remove expired or discontinued medications from medication carts and dispose of them per facility policy.
Incomplete Documentation of Outpatient Follow-Up Appointments
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for two residents who had physician referral outpatient appointments. Resident ID #10, admitted with diagnoses including heart failure and a fall, had a hospital discharge summary noting a witnessed fall with head injury and a planned follow-up within 2 weeks to discuss hernia repair. After a general surgery visit on 3/5/2026, the nursing progress note stated the appointment was canceled and rescheduled, and the Communication Tab was updated to a new appointment date. However, the record did not contain a Continuity of Care (COC) report from that visit, and there was no evidence the resident attended the rescheduled appointment. Surveyor interviews with the surgery office showed the resident was a no-show for a later appointment and was rescheduled again, while the facility scheduler stated she was not aware of the follow-up appointments and transportation had not been scheduled. The DNS was unable to provide the COC and stated the scanning process for medical records was delayed. Resident ID #104, admitted with a diagnosis including a left artificial hip joint, had a nursing progress note documenting a return from an orthopedic appointment related to a failed total arthroplasty and noting that dental clearance was needed before surgery could be scheduled. The record did not contain the COC report from the orthopedic appointment, and there was no evidence that the orthopedic instructions were reviewed with the provider or implemented. During surveyor interview, the orthopedic office administrator confirmed the resident had been evaluated for a left hip replacement and faxed the COC to the surveyor. The COC documented severe pain, inability to ambulate, failed left hip replacement needing another surgery, and instructions for dental evaluation, bone health referral, bone density scan, and cardiac clearance prior to surgery. The DNS again could not provide the COC and stated the document could be in an office because scanning was delayed.
Failure to Reweigh and Report Significant Weight Loss
Penalty
Summary
The facility failed to ensure acceptable nutritional status for a resident with diagnoses including fractured left hip and dysphagia after the resident experienced severe weight loss and other significant weight changes. The resident’s record showed a weight of 102.4 lbs. on 1/5/2026 and 84 lbs. on 2/5/2026, reflecting an 18.4 lb. loss in one month. The record did not show that the resident was reweighed within 72 hours of the 2/5/2026 weight to confirm and verify the loss per facility policy, and the Registered Dietitian was not notified until 2/17/2026, 12 days after the severe weight loss was identified. Further record review showed additional weight fluctuations without evidence of required reweighing, including a gain from 86.4 lbs. on 2/23/2026 to 93.4 lbs. on 3/2/2026 and a loss from 93.4 lbs. on 3/2/2026 to 85.6 lbs. on 3/9/2026. During interview, the RD stated she is notified of significant weight changes by nursing staff and by a monthly report, and that residents with discrepancies of 3 lbs. or more in a week or 5 lbs. or more in a month are usually reweighed the same day. The DON acknowledged that reweighs were not obtained after the resident’s severe weight loss and subsequent significant weight changes, despite the facility policy requiring confirmation and notification.
Facility Assessment Lacked Family and Resident Representative Input
Penalty
Summary
The facility assessment failed to include active involvement and input from resident representatives and family members. Record review of the facility document titled, "Requirements of Participation: Facility Assessment," reviewed and approved on 1/21/2026, did not reveal evidence that the facility developed and maintained a plan that included involvement by residents' families and/or representatives. During an interview on 3/26/2026 at 2:48 PM, the Director of Nursing Services acknowledged that the facility assessment did not include input from resident representatives or families.
Failure to Ensure Timely Refill and Administration of Pramipexole for RLS
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of pramipexole for a resident with restless leg syndrome (RLS) and seizures. The resident was admitted in January 2026 and had intact cognition, as evidenced by a Brief Interview for Mental Status score of 15 out of 15. A physician’s order dated 1/23/2026 directed that pramipexole dihydrochloride 0.5 mg, two tablets by mouth twice daily, be administered for RLS. Review of the February 2026 Medication Administration Record showed that this medication was not administered as ordered on nine occasions between 2/8/2026 and 2/12/2026, with doses missed on multiple mornings and afternoons. The resident reported going about three days without receiving pramipexole because it was not available, and stated that this resulted in uncomfortable leg sensations, pain radiating to the back, and the need to pace around the unit due to discomfort when sitting still. A progress note dated 2/11/2026 documented that the pharmacy failed to deliver the ordered pramipexole and that the resident requested transfer to the Emergency Department to access the medication. During interviews, the Director of Nursing Services acknowledged that the medication was not administered as ordered on the identified dates because it was unavailable from the pharmacy, and the Pharmacy Account Manager stated that the refill request for pramipexole was not submitted by the facility until 2/12/2026.
Failure to Complete Diagnostic Testing, Report Lab Results, and Notify Responsible Party
Penalty
Summary
The facility failed to ensure that ordered diagnostic testing was completed and that significant laboratory results were reviewed and reported to the practitioner for a resident being treated for a herpes simplex outbreak. Specifically, a genital swab ordered by the nurse practitioner was documented as obtained, but there was no evidence that the swab was processed or that results were received or followed up on. Additionally, a urinalysis with culture and sensitivity (UA C&S) was ordered and resulted in a positive urinary tract infection (UTI), but the results were not reported to a provider until four days after they became available, delaying appropriate treatment. The resident involved had a history of dementia, malignant neoplasm of the colon, and was dependent on staff for activities of daily living, including incontinence care. The care plan identified the resident as being at risk for skin breakdown, with interventions to inspect the skin during care. Despite these risks, the resident experienced worsening genital lesions, swelling, and redness over several months, with multiple assessments and new orders for treatment, but without timely completion or follow-up of diagnostic tests as ordered by the practitioner. Furthermore, the facility did not ensure timely communication with the resident's responsible party regarding changes in condition, new diagnoses, or new medications prescribed. Interviews with staff and the Director of Nursing confirmed that the genital swab was not followed up on, the positive UA results were not promptly reported, and the resident's family was not notified of significant changes in the resident's condition. These failures collectively resulted in delays in treatment and the need for more invasive interventions.
Failure to Implement Timely Bed Rail Safety Measures Results in Resident Injury
Penalty
Summary
The facility failed to ensure that staff updated and implemented proper safety measures, specifically regarding the use of bed rails, which resulted in a preventable fall and significant injury to a resident. The resident, who had a history of dementia, left hip fracture, and previous falls, was readmitted to the facility and experienced a decline in mobility after a fall while ambulating. Physical therapy evaluated the resident and recommended the use of side rails to assist with bed mobility and transfers, with the plan of care signed by a physician. However, the care plan was not updated to reflect the need for side rails, and there was a delay of approximately 20 days before the side rails were installed on the resident's bed. On the day of the incident, the resident fell out of bed and was found on the floor by a nursing assistant, complaining of back and leg pain. Progress notes indicated ongoing pain and a lack of effective pain management, with a delay in obtaining an X-ray to assess the extent of the injury. The X-ray, when finally completed, revealed a left femoral neck fracture and pelvic fracture, requiring the resident to be sent to the emergency department and subsequently undergo surgery. The resident, who had previously been ambulatory with a walker, now required a wheelchair and assistance from two staff members for mobility. Interviews with staff confirmed that the resident did not have side rails in place at the time of the fall, despite the physical therapy recommendation and physician's order. The Director of Nursing and other staff acknowledged the absence of side rails and the delay in their installation. The failure to update the care plan and implement the recommended safety measures directly contributed to the resident's fall, resulting in significant injury and a marked decline in functional status.
Improper Disposal of Garbage and Refuse Due to Lapsed Trash Removal Services
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse in accordance with professional food safety standards. Surveyor observation, record review, and staff interviews revealed that garbage bags were left outside the dumpster, which is not compliant with the 2022 FDA Food Code requirements for refuse storage and removal. Specifically, the code prohibits the outside storage of refuse in unprotected bags and requires removal at a frequency that prevents the attraction or harboring of pests. A community complaint reported to the Rhode Island Department of Health alleged that overflowing garbage was attracting pests and creating a risk of disease. Photographic evidence provided by the complainant showed multiple garbage bags accumulated next to the dumpsters. An email from the facility Administrator confirmed that the waste management company had placed a hold on trash removal services due to nonpayment, resulting in trash bags accumulating in the parking lot. During an interview, the Administrator acknowledged that the trash removal company had stopped pickups without notice, leading to the accumulation of garbage on the premises.
Failure to Provide Required Two-Person Assistance During Resident Care Results in Fall and Injury
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for bed mobility and personal hygiene and required the assistance of two staff members during care, was provided care by only one nursing assistant. The resident had significant medical conditions, including anoxic brain damage, seizures, and diabetes, and was documented in both the Minimum Data Set (MDS) and care card as needing two staff for bed mobility and hygiene tasks. Despite these documented requirements, the nursing assistant performed a full bed bath and attempted to change the resident alone, during which the resident rolled out of bed and sustained injuries, including a facial laceration and abrasions, necessitating immediate transfer to the hospital. Interviews with staff revealed that the nursing assistant was unaware of the documented requirement for two-person assistance and typically worked alone with the resident. The Director of Nursing Services also did not acknowledge the two-person requirement, despite its presence in the resident's care documentation. As a result of the failure to follow the care plan and MDS directives, the resident experienced a fall with multiple injuries and required hospitalization.
Failure to Provide Appropriate ROM and Mobility Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to residents with limited range of motion (ROM) and contractures, as well as to a resident with limited mobility. Resident ID #67, who was admitted with anoxic brain damage and muscle wasting, was observed to have a contracted left hand without any interventions in place to prevent further decrease in ROM. Despite the resident's severe cognitive impairment, staff interviews revealed that no physical or occupational therapy was being provided, and the care plan did not address the contracture or include interventions to prevent further decline. Resident ID #79, admitted with spinal stenosis and peripheral autonomic neuropathy, was also found to have bilateral hand contractures and limited ROM, yet was not receiving therapy services. The care plan failed to document these issues, and no evidence was found of a therapy evaluation or interventions to prevent further decline. Staff interviews indicated a lack of awareness of the resident's condition and the absence of necessary therapy evaluations and interventions. Resident ID #272, admitted for respite care with reduced mobility and a history of poliomyelitis, had not been out of bed since admission and lacked a wheelchair. Despite the resident's expressed desire to get out of bed, staff had not facilitated this, and no therapy screen had been conducted to assess the need for adaptive equipment. It was only after surveyor intervention that a therapy screen was completed, revealing the resident required assistance for transfers and needed a wheelchair.
Failure to Prevent Pressure Ulcers in Resident with Reduced Mobility
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent new pressure ulcers from developing for a resident admitted for respite care. The resident, who had reduced mobility and a history of poliomyelitis, was admitted without any wounds. However, within six days, the resident developed a facility-acquired wound on the right buttocks. The resident's care plan indicated a risk for skin breakdown due to impaired mobility, and a Norton Assessment identified the resident as being at moderate risk for developing pressure ulcers. Despite the resident's intact cognition and expressed desire to be out of bed, staff did not transfer the resident out of bed for 15 consecutive days. The resident was observed lying flat on their back during multiple surveyor observations, and staff interviews revealed a lack of awareness and action regarding the resident's mobility needs. The resident's care card indicated a need for assistance from two staff members for bed mobility and transfers, yet this was not implemented. The resident's wound care was also inadequately managed, as evidenced by a soiled dressing not being changed as ordered. The wound nurse identified new pressure areas with non-blanchable redness, indicating the development of pressure ulcers. The Director of Nursing Services acknowledged that staff should have offered to transfer the resident out of bed, highlighting a failure in the facility's care practices that led to the resident developing a pressure ulcer.
Deficiencies in Food Safety and Storage Practices
Penalty
Summary
The facility was found to have deficiencies in food storage, preparation, distribution, and service according to professional standards. Surveyor observations on multiple dates revealed significant grease accumulation on various kitchen equipment, including the steamer, food warmer, stove, and food meal delivery carts. Additionally, the utility cart storing spice containers was noted to have crumbs and debris in the corners. In the main dining room, the steam table was observed with grease accumulation on the knobs and food spills on the front of the unit. These observations indicate a failure to maintain nonfood contact surfaces free of dirt, dust, food residue, and other debris as required by the Rhode Island Food Code 2018 Edition. Furthermore, the facility failed to procure food from approved sources. During a surveyor observation, a dozen eggs with a use-by date of 12/14/2024 were found stored in a gray egg container in the main kitchen's reach-in refrigerator. These eggs were revealed to be fresh farm eggs brought in by a staff member from his farm-raised chickens, which is not compliant with the Rhode Island Food Code 2018 Edition that mandates food to be obtained from sources that comply with the law. The facility administrator acknowledged the need for cleaning the food service equipment and the improper storage of eggs brought from home.
Failure to Follow Physician's Orders and Medication Refusals
Penalty
Summary
The facility failed to meet professional standards of quality by not following physician's orders for several residents. One resident with Parkinson's disease and hypertension refused medications multiple times throughout January 2025, including Amlodipine, Lisinopril, Metoprolol, Multivitamin, and Carbidopa-Levodopa. The facility did not notify the provider of these refusals, as confirmed by the Director of Nursing Services and the Nurse Practitioner during interviews. Another resident with dysphagia and dementia had a dietary order to avoid straws with liquids, yet surveyor observations noted the presence of straws on multiple occasions. Staff members, including a Registered Nurse and a Nursing Assistant, were unaware of the order until informed by the surveyor. The Director of Nursing Services acknowledged the oversight and confirmed the expectation that straws should not be provided to the resident. Additionally, a resident with Diabetes Mellitus Type 2 had blood sugar readings exceeding 400 on several occasions, but the provider was not notified as required by the physician's order. Furthermore, a resident with a wound on the right buttocks did not receive timely dressing changes as ordered, with a dressing observed to be overdue for change. These deficiencies were acknowledged by the Director of Nursing Services, who confirmed the expectation for adherence to physician orders.
Failure to Monitor Suicidal Ideation in Resident
Penalty
Summary
The facility failed to ensure that a resident with a history of mental disorders and suicidal ideations received appropriate treatment and services to maintain their mental and psychosocial well-being. The resident, admitted in January 2025, had diagnoses including suicidal ideations, bipolar disorder, and PTSD. Despite being cognitively intact, the resident showed signs of moderately severe depression. A consult service document highlighted the resident's chronic risk of suicide ideation, recommending monitoring for suicidal ideation and discussing a behavioral plan with staff. However, the care plan dated 1/8/2025 did not include interventions for monitoring suicidal ideation, nor was there evidence of a behavioral plan related to this issue. The January 2025 Treatment Administration Record and nursing progress notes lacked documentation of behavioral monitoring for suicidal ideation. During interviews, both a registered nurse and the Director of Nursing Services were unable to provide evidence of monitoring the resident's behavior related to suicidal ideation, indicating a lapse in the facility's responsibility to provide necessary behavioral health care and services.
Failure to Provide Resident-Centered Activity Program
Penalty
Summary
The facility failed to provide an ongoing activity program tailored to a resident's preferences and needs, as identified in their comprehensive assessment and care plan. The resident, who was readmitted in September 2024 with diagnoses including mild communication deficit and major depressive disorder, expressed a strong preference for activities such as reading, listening to music, and participating in group activities. Despite these preferences being documented in the resident's care plan, observations on multiple dates revealed that the resident was left alone in their room without engagement in any activities, such as watching television or listening to music. Interviews with staff members revealed a lack of adherence to the resident's care plan. A Nursing Assistant indicated that the resident preferred to stay in their room and was supposed to receive visits from the activities department for in-room activities. However, the assigned Activities Aide admitted to not visiting the resident on the observed dates. Additionally, the Director of Nursing Services expected Nursing Assistants to facilitate the resident's engagement with television or music, as per the care plan, but this was not done. This lack of action resulted in the resident not participating in any activities, contrary to their documented preferences and care plan interventions.
Failure to Maintain Residents' Nutritional Status
Penalty
Summary
The facility failed to ensure that residents maintained acceptable nutritional status, as evidenced by significant weight loss in two residents. Resident ID #52, who was readmitted with dementia and dysphagia, experienced an 8-pound weight loss over two weeks. The facility's policy required weekly weights for residents with significant weight changes, but weights were not obtained for Resident ID #52 during the weeks of 12/29/2024 through 1/4/2025. Additionally, there was no evidence of re-weighing or further interventions after the weight loss was documented on 1/6/2025, until the issue was identified by the surveyor. Resident ID #272, admitted with poliomyelitis and depression, also experienced weight loss, losing 1.3 pounds in 10 days. The facility failed to obtain weekly weights as per policy, and there was no evidence of a nutritional care plan or an admission nutritional assessment by the dietitian. Although the dietitian assessed the resident on 1/20/2025 and recommended a nutritional supplement, there was no documentation of this assessment or communication of the recommendation to the facility. Interviews with the dietitian and the Director of Nursing Services (DNS) revealed that the facility did not follow its policy of notifying the interdisciplinary team, dietitian, physician, and family of significant weight loss. The DNS acknowledged the expectation for re-weighing and notification but could not provide evidence of these actions for either resident. The lack of adherence to the facility's policies and procedures contributed to the deficiency in maintaining the residents' nutritional status.
Medication Storage Security Breach
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with accepted professional principles, as observed during a survey. The facility's policy requires that medications be stored in a locked mobile medication cart accessible only to licensed nursing personnel, and other medications be stored in a locked medication room. However, during a medication administration pass, it was observed that the keys to the medication cart and storage room were on the same key ring as the only key to the unit's bathroom. This key ring was shared among staff members, including non-licensed personnel, to access the bathroom, which compromised the security of the medication storage. During interviews, staff members, including a Certified Medication Technician (CMT), a Licensed Practical Nurse (LPN), and a housekeeper, confirmed that the medication technician's key ring was used by various staff members to access the bathroom. The Director of Nursing Services acknowledged that the bathroom key should be separate from the medication storage keys and could not provide evidence that the medication storage areas were only accessible to licensed nurses or medication technicians, as required by the facility's policy.
Failure to Follow Physician's Orders and Maintain Accurate Records
Penalty
Summary
The facility failed to maintain accurate medical records and adhere to physician's orders for several residents. Resident ID #83, who was readmitted with conditions including contracture of the right knee and vascular dementia, was identified as being at high risk for pressure ulcers. Despite physician's orders to offload the resident's heels and apply heel protectors every shift, surveyor observations revealed these orders were not followed on multiple occasions. The Treatment Administration Record (TAR) inaccurately indicated that these orders were completed, which was acknowledged by Registered Nurse, Staff G. Similarly, Resident ID #46, with diagnoses including muscle weakness and major depressive disorder, had orders to offload heels every shift. Observations showed these orders were not followed, and Registered Nurse, Staff F, confirmed the inaccuracy in the TAR. Additionally, Resident ID #272, diagnosed with poliomyelitis, had a physician's order for a specific wound dressing change that was not completed as required. The dressing was not changed on the specified date, despite the TAR indicating otherwise. This was confirmed by Registered Nurse, Staff B, and acknowledged by the Director of Nursing Services, who expected adherence to physician's orders and accurate documentation.
Inadequate Disinfection of Glucometer
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the disinfection of a glucometer used for multiple residents. The facility's policy, revised in October 2018, required that blood glucose monitoring equipment be cleaned with bleach wipes before and after use, or as per manufacturer guidelines. However, the manufacturer's instructions for the Embrace Pro glucometer specified cleaning with a moist cloth or tissue using isopropyl alcohol or mild detergent with water. During an observation, a registered nurse did not clean the glucometer before or after obtaining a resident's blood sugar, nor did she disinfect it before returning it to the medication cart. The resident involved was readmitted to the facility in July 2023 with a diagnosis of type 2 diabetes mellitus and had a physician's order for Humalog insulin to be administered based on blood sugar readings. During an interview, the registered nurse acknowledged her failure to clean the glucometer as required. The Director of Nursing Services confirmed that the expectation was for the glucometer to be cleaned with a bleach wipe before and after use. This deficiency was identified during a surveyor observation and interview process.
Failure to Notify Residents of Medicaid Eligibility Risk
Penalty
Summary
The facility failed to notify residents or their representatives who receive Medicaid benefits when their personal needs account balance reached $200 less than the Social Security Income (SSI) resource limit. This deficiency was identified for four residents, each with account balances exceeding $4,000. According to the Title 210-Executive Office of Health and Human Services, Chapter 50-Medicaid Long-Term Services and Supports (LTSS), facilities are required to provide written notification to residents when their account balance approaches the resource eligibility guideline to prevent jeopardizing Medicaid eligibility. During a survey, the Account Receivable Assistant was unable to provide evidence of such notifications being issued to the affected residents.
Failure to Conduct Weekly Skin Audits
Penalty
Summary
The facility failed to meet professional standards of quality by not adhering to physician's orders for weekly skin audits for three residents. Resident ID #3, admitted with severe protein calorie malnutrition, had a physician's order for weekly skin checks, but the last recorded audit was on 5/27/2024, indicating no assessments were conducted in June and July 2024. Similarly, Resident ID #4, also diagnosed with protein calorie malnutrition, had a physician's order for weekly skin checks, but the last audit was recorded on 6/30/2024, showing no assessments in July 2024. Resident ID #5, diagnosed with Alzheimer's disease, had a physician's order for weekly body audits, but the last recorded audit was on 7/5/2024, indicating a lapse of three consecutive weeks without assessment. During an interview, the Director of Nursing Services could not provide evidence that the required weekly skin audits were completed for these residents, as per the physician's orders.
Failure to Monitor Nutritional Status and Record Meal Intakes
Penalty
Summary
The facility failed to adequately monitor and maintain the nutritional status of two residents, leading to deficiencies in their care. For Resident ID #1, the facility did not consistently use the same scale for weighing, as required by their policy, and failed to obtain a reweigh after a significant weight change. Additionally, there were numerous instances where meal intakes were not recorded, making it difficult to assess the resident's nutritional intake accurately. The Director of Nursing Services was unable to provide evidence of consistent weighing practices or complete meal intake records during the surveyor interview. For Resident ID #3, the facility did not obtain a weight measurement for the entire month of June, despite the resident's diagnosis of severe protein calorie malnutrition. The resident's care plan required monitoring of food and fluid intake, but meal intakes were frequently not recorded. Furthermore, the resident refused the prescribed nutritional supplement, Ensure Clear, on multiple occasions, yet there was no evidence that the provider or dietician was notified of these refusals. The Director of Nursing Services could not provide evidence of meal intake monitoring or communication with the provider regarding the supplement refusals.
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The facility failed to follow physician orders for post-fall care for three anticoagulated residents who experienced falls. One resident on a blood thinner with a head injury was ordered to be transferred to the ED after a telehealth evaluation, but an LPN did not send the resident, citing instructions to contact a supervisor first and inability to reach that supervisor. For two other residents on anticoagulants, providers ordered intensive neuro checks (every 15 minutes, then every 30 minutes, then hourly, then every 4 hours), but staff instead performed neuro checks only once per shift for 72 hours. The DON and Medical Director acknowledged that the transfer and monitoring orders were not implemented as written.
A resident with intact cognition and psychiatric diagnoses sustained a left eyebrow laceration when another resident with a documented history of escalating aggressive and threatening behaviors struck them with a cane during a hallway dispute. The aggressive resident had multiple prior documented incidents, including verbal threats to kill others, attacking a roommate with a cane over TV volume, throwing objects during activities, and throwing a lunch plate at staff. Despite these events, the care plan was not updated with interventions to address physical aggression toward other residents, and a psychiatric recommendation for PRN trazodone for agitation, anxiety, and insomnia was only implemented as PRN for insomnia. The failure to assess, monitor, and implement effective interventions for the aggressive resident’s behaviors led to the assault and injury and, per the report, placed this and other residents at risk of serious physical and psychosocial harm.
A resident with impulse disorder, mood and anxiety diagnoses, and a history of escalating verbal and physical aggression had multiple documented incidents of threats, object throwing, and assault with a cane. Despite a psychiatric consult recommending PRN trazodone for agitation, anxiety, and insomnia, the provider order listed insomnia only, and the care plan was not updated with specific interventions to address the resident’s physically aggressive behaviors after several documented events. Subsequently, the resident struck another resident with a cane, causing a facial laceration that required wound closure and ongoing treatment.
The facility failed to properly screen and document clearance for a NA with disqualifying criminal history information before hire, as required by its abuse, neglect, and exploitation policy. A BCI check showed disqualifying information, yet the NA was hired, completed orientation, and worked independently based only on verbal disclosure of an old drug-related charge, without written details or verification. Later, a staff member reported witnessing this NA grab a resident’s face and kiss the resident on the lips, and a community complaint alleged inappropriate interactions with the same resident, prompting involvement of local police.
A resident with anxiety disorder and PTSD was unable to attend meals and activities with peers because the facility lost the resident's clothing after it was sent to laundry. The resident was observed in a hospital gown with only a few clothing items in the room, and the record lacked an admission inventory of belongings. The DON/Administrator reported that laundry was handled by an outside vendor without a tracking system or item documentation.
A resident with dementia and severely impaired cognition was subjected to repeated non-consensual kissing on the lips by an NA, who entered the resident’s room during care, verbally expressed affection, and then kissed the resident on the mouth on at least two separate occasions witnessed by staff. One staff member delayed reporting the first incident due to fear of the NA. These actions occurred despite a facility policy defining sexual abuse as any non-consensual sexual act and requiring protections of residents’ rights and well-being.
Failure to investigate allegations of resident-to-resident sexual inappropriateness: A resident with dementia and TBI was documented as being inappropriate with another resident, and psych notes later described increased sexually inappropriate behaviors toward other residents. Staff interviews showed the resident had been observed touching others and needing frequent redirection, but the DON, ADON, and Administrator acknowledged the facility did not complete an investigation or recognize the allegation as possible abuse.
A resident with dementia and a hearing deficit did not receive ear care as ordered because the chart lacked the Debrox order and the ear was flushed before the intended Debrox course was completed. In a separate incident, staff witnessed inappropriate kissing of a resident with dementia, but the allegation was not reported to the provider and the care plan was not updated. A third resident’s wound care was also not completed as ordered when an RN used normal saline instead of the prescribed Vashe wound wash.
A resident with migraines and chronic pain did not receive timely pain management after repeatedly reporting a migraine and appearing in visible distress. An NA notified an LPN, an RN said she could not access the med cart, and the resident continued waiting while the LPN was off the unit; the PRN migraine medication was not given until 40 minutes after the first complaint. The DON acknowledged the resident should not have waited that long for pain medication.
A resident missed 6 doses of a prescribed antibiotic, and the MAR did not show that the provider was notified. The RN acknowledged the missed doses and said they should have been reported, while the Medical Director stated she was unaware of the missed doses and would have extended the antibiotic course if informed. The DON also confirmed the missed doses and expected provider notification for any missed antibiotic dose.
Failure to Follow Post-Fall Physician Orders for Anticoagulated Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement physician orders for post-fall care, including hospital transfer and neurological monitoring, for residents on anticoagulant therapy. One resident with atrial fibrillation on Xarelto experienced an unwitnessed fall with a scalp laceration and head lump. The on-call provider, after a telehealth evaluation, ordered transfer to the ED and wrote an order directing that the resident be sent to the hospital. The resident was not transferred as ordered, and an additional order for vital signs and neuro checks every shift for 72 hours after the fall was not completed as ordered on one of the shifts. The LPN caring for this resident stated she did not send the resident to the ED because she had been instructed to call a supervisor before sending residents out, and she was unable to reach the supervisor during the shift. A second resident, also with atrial fibrillation and on Xarelto, had an unwitnessed fall with injury. The on-call provider was notified and ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, then every four hours for an additional 24 hours. A physician’s order reflecting this schedule was scanned into the EMR. However, the neuro checks were not completed as ordered; instead, they were performed only once per shift for 72 hours. The RN who authored the progress note documented the fall and the resident’s anticoagulant use, and later stated she could not remember why she did not transcribe and complete the neuro checks as ordered. A third resident with atrial fibrillation on Apixaban had a non-injury fall after attempting to walk independently. The on-call provider ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, and then every four hours for an additional 24 hours, and this order was scanned into the EMR. The record did not show that these neuro checks were completed as ordered; instead, neuro checks were documented only once per shift for 72 hours. The Medical Director stated he would have expected the first resident to be transferred to the ED as ordered and that the facility should not override a provider’s order. The DON acknowledged that the transfer order and the ordered monitoring for the first resident were not followed as written, and that for the second and third residents, staff performed only once-per-shift neuro checks instead of the more frequent monitoring ordered by the providers.
Failure to Manage Escalating Aggression Leading to Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident, Resident ID #1, from abuse by another resident with a known history of escalating aggression, Resident ID #2. Resident ID #1 was admitted in October 2025 with diagnoses including paranoid schizophrenia and adjustment disorder with mixed anxiety and depressed mood, and had a BIMS score of 14/15, indicating intact cognition. On 4/27/2026, progress notes documented that Resident ID #1 was on the receiving end of a physical altercation with another resident and was found with a deep bleeding abrasion to the left eyebrow. A subsequent nursing note described a new laceration to the left eyebrow measuring 0.5 cm by 2.0 cm by 0.1 cm, related to a resident-to-resident incident, for which wound closure strips were applied. Resident ID #1 requested police involvement and a police report, and refused transfer to the hospital for sutures. Resident ID #2 had been admitted in December 2024 with multiple psychiatric and behavioral diagnoses, including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed a BIMS score of 13/15 and documented both physical and verbal behaviors during the look-back period. Progress notes over several months recorded a pattern of escalating aggressive and threatening behaviors: on 9/13/2025, Resident ID #2 threatened to slit another resident’s throat and made additional threats toward staff; on 11/7/2025, the resident was involved in a verbal dispute with raised voice, name-calling, and verbal threats; on 12/28/2025, after another resident struck Resident ID #2 with a helmet, Resident ID #2 was overheard threatening to kill that resident if touched again. On 2/21/2026, the on-call provider documented that Resident ID #2 attacked a roommate with a cane over TV volume and required ER transfer for psychiatric evaluation. Subsequent notes on 3/9/2026 and 4/10/2026 described the resident throwing poker chips on the floor, yelling and swearing at staff and residents, and throwing a lunch plate across the nurses’ station at a nursing assistant due to dissatisfaction with portion size. Despite this documented pattern, the care plan for Resident ID #2, dated 1/16/2025, only indicated a behavior problem of being verbally aggressive toward staff with resident-to-resident altercations on 12/28/2025, 2/21/2026, and 4/27/2026, and record review failed to show added interventions to mitigate the risk of physical aggression toward other residents after the 2/21/2026 cane attack and the object-throwing incidents on 3/9/2026 and 4/10/2026. A psychiatric evaluation on 4/23/2026 recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order entered on 4/24/2026 specified trazodone 25 mg twice daily as needed only for insomnia, and record review did not show that agitation and anxiety were included as indications for use. During interviews, the RNP and the DON stated it was their expectation that agitation and anxiety would have been included in the trazodone order, and the DON was unable to provide evidence that the care plan had been updated with interventions to address Resident ID #2’s physically aggressive behaviors documented on 2/21/2026, 3/9/2026, and 4/10/2026. On 4/27/2026, the DON documented that Resident ID #2 was ambulating down the hall toward his/her room while Resident ID #1 was walking in the opposite direction, and the two residents began a verbal dispute. Before staff could intervene, Resident ID #2 used his/her cane to make contact with Resident ID #1, resulting in the eyebrow laceration that required steri-strips and ongoing wound treatment. A police incident report recorded that Resident ID #1 stated being struck with a walking cane, wanted to press charges, and that Resident ID #2 admitted to striking Resident ID #1, leading to an arrest on one count of felony assault with a dangerous weapon. The facility’s failure to assess, monitor, and implement effective interventions for Resident ID #2’s known and escalating aggressive behaviors, including failure to update the care plan after prior incidents and failure to fully implement psychiatric recommendations, resulted in this resident-to-resident altercation and injury, and the report states that this failure placed Resident ID #1 and other residents at risk of serious physical and psychosocial harm.
Failure to Implement Psychiatric Recommendations and Update Behavior Care Plan Leading to Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health services and care planning for a resident with a documented history of psychiatric conditions and aggressive behaviors. The resident was admitted in December 2024 with diagnoses including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed intact cognition with a BIMS score of 13/15 and documented physical and verbal behaviors during the look-back period. Over time, multiple behavioral incidents were recorded, including threats to slit another resident’s throat during a smoking session, verbal disputes with name-calling and threats, and a statement to another resident that if touched again the resident would be killed. Further documentation showed escalating behaviors, including an incident where the resident attacked a roommate with a cane over television volume and required ER transfer for psychiatric evaluation, throwing poker chips and yelling when not winning at Bingo, causing the roommate to avoid the shared bathroom due to inappropriate comments and frustration over the light being turned on at night, and throwing a lunch plate across the nurses’ station at a nursing assistant over portion size. The care plan, initiated in January 2025 for verbal aggression and resident-to-resident altercations, did not contain added interventions to address the resident’s physically aggressive behaviors toward others after the incidents on 2/21/2026, 3/9/2026, and 4/10/2026. The DNS later could not provide evidence that the care plan had been updated with interventions to mitigate the risk of these physically aggressive behaviors or to guide staff in ensuring the safety of other residents. On 4/23/2026, a psychiatric evaluation recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order dated 4/24/2026 implemented trazodone 25 mg twice daily as needed for insomnia only, and the record lacked evidence that agitation and anxiety were included as indications for use as recommended by the consulting psychiatrist. Both the RNP and the DNS stated it was their expectation that the trazodone order would have included agitation and anxiety. Following this incomplete implementation of the psychiatric recommendation and the lack of updated behavioral interventions in the care plan, a resident-to-resident altercation occurred on 4/27/2026 in which the resident struck another resident with a cane, causing a laceration to the left eyebrow that required closure with steri-strips and ongoing wound treatment.
Failure to Properly Screen and Clear NA with Disqualifying Criminal History
Penalty
Summary
The facility failed to ensure that a prospective employee was properly screened and cleared for a history of abuse, neglect, exploitation, or misappropriation of resident property before hire. A nursing assistant, identified as Staff A, was hired on 11/18/2025 and was working independently as a NA. Prior to hire, a Bureau of Criminal Identification (BCI) check dated 11/6/2025 showed that Staff A had disqualifying information under federal and state law. Surveyor review after discovery of the positive BCI revealed that Staff A had an extensive criminal history. Despite this, the facility proceeded with the hire and allowed Staff A to complete orientation and work independently without obtaining or maintaining documentation specifying the nature of the disqualifying information, contrary to the facility’s Abuse, Neglect and Exploitation Policy, which requires screening and documentation of proof that such screening occurred. Subsequently, a facility-reported incident submitted on 4/17/2026 documented that a staff member reported witnessing Staff A grab a resident’s face and kiss the resident on the lips. A community-reported complaint submitted on 4/22/2026 alleged inappropriate interactions between the same NA and the same resident, and included a local police incident report indicating the resident’s family intended to pursue charges related to the incident. During interviews, the Human Resource Director stated that Staff A had disclosed disqualifying information related to a prior drug-related charge from about ten years earlier, but acknowledged there was no documentation specifying the nature of the disqualifying information and that this was known only by word of mouth. The Administrator stated she was aware that the BCI contained disqualifying information and that she exercised her own judgment in proceeding with the hire, and further acknowledged she did not receive documentation detailing the disqualifying information until it was brought to her attention by the surveyor.
Failure to Maintain Resident Clothing and Dignity
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity when the resident was unable to attend meals and activities with other residents because of a lack of appropriate clothing. The resident was admitted in May 2025 with diagnoses including anxiety disorder and post-traumatic stress disorder, and a care plan revised on 8/25/2025 described the resident as highly social and willing to participate in a variety of activities, with an intervention to provide reminders of scheduled events. During observation on 4/29/2026, the resident was found in the room wearing a hospital gown while other residents were in the dining room for lunch. Only one pair of pants and two T-shirts were observed in the room. The resident stated that the facility lost all of the resident's clothing, including shirts, pants, shorts, and socks, after they were sent to laundry services several months earlier and were never returned. The resident reported that the Administrator was told about the missing clothing, but no follow-up occurred and the clothing was neither located nor replaced. The record did not contain an admission inventory list of the resident's belongings, and the Administrator stated that laundry was handled by an outsourced company without a tracking system or documentation identifying which items belonged to which resident.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse when a nursing assistant (NA) was observed kissing the resident on the lips on more than one occasion. The resident, identified as having dementia and a Brief Interview for Mental Status (BIMS) score of 0/15 indicating severely impaired cognition, had been admitted in March 2026. On one occasion, a Certified Medication Technician (CMT) reported that while she was assisting the resident with breakfast, the NA entered the room, verbally expressed affection for the resident, made a kissing noise, leaned forward, and kissed the resident on the lips. This incident made the CMT uncomfortable, and she later discussed it with another NA. A separate staff member, another NA, reported that two days earlier she had observed the same NA enter the resident’s room while morning care was being provided, ask the resident if they remembered her, state that she loved the resident, then lean toward the resident, make a kissing sound, and kiss the resident on the mouth with full lip-to-lip contact. This second NA did not report the incident at the time because she was fearful of the NA involved and only came forward after learning of the later incident. The facility’s abuse, neglect, and exploitation policy defined sexual abuse as a non-consensual sexual act of any type with a resident and required protections for each resident’s health, welfare, and rights, as well as screening of potential employees for a history of abuse. Despite this policy, the resident with severely impaired cognition was subjected to repeated non-consensual kissing by the NA.
Failure to Investigate Allegations of Resident-to-Resident Sexual Inappropriateness
Penalty
Summary
The facility failed to ensure that allegations made by residents were recognized as possible abuse by staff and that all allegations were investigated for Resident ID #41, who was admitted with diagnoses including dementia and traumatic brain injury. A facility policy titled, Abuse, Neglect and Exploitation, stated that an immediate investigation is warranted when suspicion of abuse, neglect, exploitation, or reports of abuse, neglect, or exploitation occur. A progress note written by an RN documented that a resident reported Resident ID #41 was being inappropriate with another resident. Subsequent records included psychiatric evaluations stating the resident was being seen due to increased sexually inappropriate behaviors toward other residents and that sexual impulses may present an unsafe environment for other patients in the facility. Staff interviews revealed that Resident ID #41 had been observed touching other residents' shoulders and hands and required frequent redirection. The RN who documented the incident stated the behavior involved an attempted hug without contact and that both residents were separated and assessed, while the ADON and DON acknowledged they were unaware of the behavior or that the facility had not investigated the allegations. The Administrator also acknowledged that an investigation had not been completed to determine what sexually inappropriate behavior had occurred and that staff did not identify the allegation as possible abuse or investigate it immediately.
Failure to Follow Orders, Report Abuse, and Perform Ordered Wound Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for a resident with dementia and anxiety disorder who had a hearing deficit and complained of right ear wax buildup. The medical record showed an order for Debrox ear drops and a separate order to flush the right ear with warm water two times a day following Debrox usage for 5 days, but the record did not include a physician order for the Debrox solution. The April 2026 MAR showed the resident’s right ear was flushed six times, and the resident stated that the right ear still felt blocked. The RN acknowledged flushing the ear and was unaware whether Debrox had been given, while the DON stated the order had been entered incorrectly and that the ear should not have been flushed before Debrox administration. The NP stated the intended order was for Debrox twice daily for five days before irrigation and that she would not have ordered daily ear flushing. The facility also failed to report an allegation of abuse and failed to update the care plan for a resident with dementia after staff reported inappropriate interactions with a nursing assistant. A community complaint and police incident report indicated the family wanted to press charges, and the Administrator and DON confirmed that staff had reported witnessing the nursing assistant kiss the resident on two occasions. The record did not show that the allegation was reported to the provider, and the comprehensive care plan was not updated to reflect the allegation or any interventions related to the incident. The NP stated she was unaware of the incident and would have expected to be notified, and the ADNS acknowledged that the provider had not been notified and the care plan had not been updated. The facility further failed to follow a wound care order for a resident readmitted with peripheral vascular disease and cellulitis of the lower limb. The physician ordered cleansing open areas on the left lower leg with Vashe wound wash, applying xeroform to the wound bed, and wrapping with kling. During observation, the RN performing wound care did not use Vashe wash and instead cleansed the wound with normal saline. The RN acknowledged using normal saline rather than the ordered cleanser, and the DON stated she would expect the nurse to follow the wound orders as written.
Delayed Pain Medication for Resident with Migraine
Penalty
Summary
Safe, appropriate pain management was not provided for Resident ID #17, who was admitted with diagnoses including migraines and chronic pain. The resident’s care plan dated 4/20/2026 included a goal for the resident to verbalize adequate pain relief and an intervention to respond immediately to any complaint of pain. The physician ordered Butalbital-APAP-Caffeine 50-300-40 mg, 1 capsule every 12 hours as needed for migraine pain. On 4/29/2026 at 10:30 AM, the resident was observed in the hallway complaining of a migraine, moaning in pain, and holding his/her head. At 10:34 AM, an NA reported to an LPN that the resident wanted pain medication, and at 10:37 AM the resident continued to complain of migraine pain and told an RN about the pain, but the RN stated she did not have keys to the medication cart and could not get any pain medication. The resident continued to complain of severe head pain, returned to the room to lie down at 10:40 AM, and the LPN was still off the unit at 10:42 AM. The resident was not assessed when the LPN returned, and the medication was not administered until 11:10 AM, 40 minutes after the initial complaint. The resident later reported pain rated 7 out of 10, and the DON acknowledged that a resident should not wait 40 minutes for pain medication.
Missed Antibiotic Doses Not Reported to Provider
Penalty
Summary
The facility failed to ensure that Resident ID #17 was free from significant medication errors when the resident missed 6 doses of a prescribed antibiotic. The resident was admitted in April 2026 with diagnoses including surgical aftercare and complication of surgical and medical care, and had a physician order dated 4/3/2026 for Cefadroxil 500 mg by mouth twice daily for 14 days. Review of the April 2026 MAR showed missed doses on 4/3 at 8:00 PM, 4/6 at 8:00 PM, 4/11 at 8:00 PM, 4/12 at 8:00 AM, 4/14 at 8:00 PM, and 4/17 at 8:00 AM. The record did not show that the provider was notified of the missed antibiotic doses. During interview, the RN acknowledged the 6 missed doses and stated they should have been reported to the provider. The Medical Director stated she was unaware of the missed doses and said she would have extended the antibiotic course if she had known. The DON also acknowledged the missed doses and stated she would expect the provider to be informed if a resident misses any dose of an antibiotic.
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