Bayberry Commons
Inspection history, citations, penalties and survey trends for this long-term care facility in Pascoag, Rhode Island.
- Location
- 181 Davis Drive, Pascoag, Rhode Island 02859
- CMS Provider Number
- 415080
- Inspections on file
- 29
- Latest survey
- July 18, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Bayberry Commons during CMS and state inspections, most recent first.
Pharmacy consultant recommendations for medication regimen irregularities were not addressed by the attending physician for three residents, including those with back pain, Alzheimer's disease, and dementia. Recommendations included clarifying medication orders and adding appropriate diagnoses, but there was no evidence of physician review or action until surveyors brought the issues to the facility's attention.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with dementia and major depressive disorder did not receive an increased dose of sertraline as recommended by psychiatric services and approved by the provider, because the facility placed the order on hold pending POA consent. After an initial attempt to contact the POA, there was no further documented effort to obtain consent, and the provider was unaware the medication change had not been implemented.
A resident with a history of dysphagia had a change in physician's diet orders from aspiration precautions to a regular diet with thin liquids. Despite this, the TAR continued to be signed off as if aspiration precautions were still in place. Staff interviews confirmed that the outdated order was no longer active, but documentation was not updated accordingly, resulting in inaccurate medical records.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the plan was not prepared, reviewed, and revised by a team of health professionals as required.
A facility failed to notify a resident's physician of significant changes in the resident's condition, including lethargy and unresponsiveness, over several days. The resident, with a history of heart disease and reduced mobility, showed signs of deterioration, such as refusal of medication and meals, and was intermittently unarousable. Despite these changes, the physician was not notified until several days later, and vital signs were not documented. The resident was eventually hospitalized with respiratory failure, pneumonia, and a UTI, and later transferred to hospice care.
A resident with heart disease and other conditions did not receive several prescribed medications over three days. The facility's policy requires notifying the physician when medications are missed, but there was no evidence of such notification. The DNS acknowledged the lack of documentation, and the physician was unaware of the missed doses.
A facility failed to protect a resident from sexual abuse, as two residents with severe cognitive impairments were found engaging in sexual acts multiple times. Despite initial separation and 15-minute checks, the facility did not effectively monitor or intervene, leading to repeated incidents. Staff interviews confirmed the lack of consistent documentation and interventions, and the facility's leadership acknowledged the deficiency.
A facility failed to provide proper respiratory care for a resident with congestive heart failure and shortness of breath. Despite the resident's need for continuous oxygen therapy, there was no physician's order specifying the required oxygen flow and method. The deficiency was identified after the resident was hospitalized due to breathing difficulties, and staff interviews confirmed the lack of necessary documentation and orders.
A facility failed to maintain accurate medical records for a resident receiving oxygen therapy. Despite hospital records indicating the resident was on 3L of oxygen, the facility only had an order for 1L as needed. Progress notes showed varying oxygen levels, but these were not documented in the Medication Administration Record. Staff interviews revealed inconsistencies in documentation, with the DON unable to provide complete records.
A resident identified as a high fall risk was not provided with hip protectors, as required by their care plan, leading to a fall and a right femur fracture. The resident, who had severe cognitive impairment, was ambulating with staff when they tripped. An LPN noted the protectors were unavailable due to being soiled, and there was no documentation of the resident refusing them. The DON could not provide evidence that the protectors were offered or refused.
A resident with a history of falls was found to have two alarms engaged while in a wheelchair, which were not easily removable, indicating potential restraint use. The facility failed to provide evidence of assessments or ongoing evaluations for the alarms' necessity and effects. Staff interviews revealed a lack of awareness about any assessments, and the administration could not demonstrate that the alarms were the least restrictive intervention.
The facility failed to conduct comprehensive assessments for five residents and a Significant Change in Status Assessment (SCSA) for a resident admitted to hospice. Comprehensive assessments, which include the Minimum Data Set (MDS) and Care Area Assessment (CAA) process, were incomplete due to missing CAA documentation. Additionally, the required SCSA was not completed for a resident after admission to hospice services, as confirmed by the ADNS.
The facility failed to ensure accurate MDS assessments for several residents, leading to discrepancies in their medical records. A resident with repeated falls was inaccurately documented as using alarms less than daily, while another resident with nicotine dependence was incorrectly noted as not using tobacco. Additionally, a resident with a history of MRSA was still coded as having an active MDRO, and a resident with urine retention was inaccurately documented as having an indwelling catheter. The MDS Coordinator acknowledged these inaccuracies, and the administration could not provide evidence of accurate assessments.
A facility failed to maintain an infection prevention and control program for a resident with MRSA colonization. The resident's care plan aimed to prevent MRSA spread, but the facility did not conduct timely MRSA screenings or maintain required precautions. Observations confirmed the absence of necessary precautions, and staff could not provide evidence of an effective infection control program.
A resident on anticoagulant medication experienced an unwitnessed fall with a head strike and a subsequent headache. The NP was notified of the fall but not the headache, and gave a verbal order for neurological assessments and vital signs every shift for 72 hours. This order was not transcribed or executed, leading to a deficiency in care.
A resident with dysphagia was not provided food in a form suitable for their mechanical soft diet, receiving whole sausage links and bacon instead. Staff, including a nurse and cook, acknowledged the error, and the Assistant Director of Nursing Services confirmed the oversight.
Failure to Address Pharmacist-Identified Medication Irregularities
Penalty
Summary
The facility failed to ensure that drug regimen review (MRR) irregularities identified by the consultant pharmacist were addressed by the attending physician for three residents. For one resident with lower back pain and a spinal compression fracture, a pharmacy recommendation to specify the application area for a lidocaine patch was not acted upon. In another case, a resident with Alzheimer's disease had pharmacy recommendations regarding the administration of Miralax and clarification of vitamin D therapy, which were not addressed despite repeated notes from the consultant pharmacist. A third resident with dementia, vitamin D deficiency, and folate deficiency anemia had recommendations to add appropriate diagnoses for several medications, but these were also not addressed. Record review and staff interviews confirmed that there was no evidence the MRR irregularity recommendations were reviewed or acted upon by the physician for these residents, and the Director of Nursing Services was unable to provide documentation of follow-up. The facility's policy requires monitoring of consultant pharmacy services and timely response to identified irregularities, but this was not followed in these cases until the issues were identified by surveyors.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence or inadequacy of a comprehensive infection prevention and control program, but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Implement Psychiatric Medication Recommendation Due to Incomplete Consent Process
Penalty
Summary
A deficiency was identified when the facility failed to implement a psychiatric recommendation for a resident with dementia and major depressive disorder. The psychiatric provider recommended an increase in sertraline to 50 mg daily due to inappropriate behaviors, and this recommendation was approved by the resident's provider. However, the facility placed the new order on hold pending consent from the resident's Power of Attorney (POA). Documentation shows that a call was made to the POA to obtain consent, and a message was left, but there was no further evidence of additional attempts to contact the POA or obtain consent after that date. Interviews with staff confirmed that the facility's process requires obtaining and documenting consent from the resident representative before implementing changes to psychotropic medications. The LPN and DON both indicated that documentation of attempts to obtain consent should be present in the progress notes, but no such documentation was found after the initial attempt. The resident's provider was unaware that the medication increase had not been implemented and believed the resident was already receiving the higher dose.
Failure to Accurately Document and Update Medical Records for Diet Orders
Penalty
Summary
The facility failed to maintain accurate medical records and documentation in accordance with professional standards for a resident with a physician's order for aspiration precautions. The resident, who had diagnoses including Alzheimer's disease and a history of dysphagia, was readmitted with an order for aspiration precautions such as head of bed elevation, staff assistance during meals, oral care after eating, nectar thick fluids, and a puree diet. Subsequently, a new physician's order was issued for a regular house diet with thin liquids. Despite this change, the Treatment Administration Record (TAR) continued to reflect that aspiration precautions were being implemented and signed off as completed three times daily, even after the new diet order was in place. Surveyor observation revealed the resident eating alone with thin liquids and a regular diet, contrary to the previous aspiration precautions. Interviews with staff confirmed that the order for aspiration precautions was no longer active, yet documentation on the TAR indicated otherwise. One LPN acknowledged signing off on the aspiration precautions without verifying the current diet order, and the Director of Nursing Services stated that staff are expected to document accurately. This discrepancy between actual care provided and documentation led to the deficiency.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to immediately consult with the resident's physician and notify them when there was a significant change in the resident's condition. This deficiency was identified for a resident who experienced a change in condition, including lethargy and unresponsiveness, over several days. The resident, admitted with diagnoses such as heart disease and reduced mobility, showed signs of deterioration, including refusal of medication and meals, and was intermittently unarousable. Despite these changes, there was no evidence that the physician was notified until several days later. The resident's condition continued to decline, with progress notes indicating poor fluid intake, difficulty with ambulation, and unresponsiveness to verbal stimuli. Vital signs were not documented for several days following the change in condition. The resident was eventually found to have fallen, with a significant drop in oxygen saturation, and was transferred to the hospital where they were diagnosed with hypercapnic respiratory failure, pneumonia, and a urinary tract infection. The facility's records failed to show that the physician was informed of the missed medications or the resident's deteriorating condition in a timely manner. Interviews with staff revealed that there was an expectation for the physician to be notified of such changes, but this did not occur. The Director of Nursing Services acknowledged the lack of appropriate documentation and physician notification. The resident was later transferred to hospice care following the hospital admission and passed away shortly thereafter. The facility did not have a specific policy for notifying physicians of a change in condition, contributing to the deficiency.
Failure to Notify Physician of Missed Medications
Penalty
Summary
The facility failed to meet professional standards of quality by not following physician's orders for a resident who refused medications. The resident, admitted in November 2024 with diagnoses including heart disease, acute pulmonary edema, and reduced mobility, did not receive several prescribed medications on specific dates in February 2025. These medications included Aspirin, Furosemide, Gentle Iron, Metoprolol Succinate Extended Release, Polyethylene Glycol, Warfarin, Melatonin, Simvastatin, Trazodone, and Zyprexa. The facility's Medication Administration Record (MAR) showed these medications were not administered on February 2nd, 3rd, and 4th, 2025. The facility's policy requires physician notification when a medication is not administered due to resident refusal or other reasons. However, the record review failed to show evidence that the physician was notified of the missed medications. Interviews with the Director of Nursing Services (DNS) and the resident's physician confirmed that the physician was not informed within the expected timeframe. The DNS acknowledged the lack of appropriate documentation in the resident's medical record, and the physician indicated he was not aware of the missed medications.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by multiple incidents involving two residents with severe cognitive impairments. Resident ID #1, who has dementia and a BIMS score indicating severe cognitive impairment, was found in compromising situations with Resident ID #2, who also has dementia and was unable to complete a BIMS assessment due to cognitive limitations. Both residents were observed engaging in sexual acts, despite their inability to consent due to their cognitive conditions. The incidents occurred on a secured unit, where staff initially separated the residents after observing inappropriate behavior. However, the residents were later found in similar situations multiple times, indicating a lack of effective monitoring and intervention. The facility's policy on abuse prohibition requires an evaluation of a resident's capacity to consent to sexual activity, which was not adequately addressed in this case. The 15-minute checks implemented after the initial incident were not consistently documented, and no new interventions were put in place after subsequent incidents. Staff interviews revealed that the residents were separated after each incident, but the measures taken were insufficient to prevent further occurrences. The facility's failure to document the 15-minute checks and implement effective interventions contributed to the ongoing risk of abuse. The Director of Nursing Services and the Administrator acknowledged the repeated incidents and the lack of evidence that the facility kept Resident ID #1 free from sexual abuse.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident who required oxygen therapy. The resident, who had diagnoses including congestive heart failure and shortness of breath, was readmitted to the facility in June 2024. Despite the resident's need for continuous oxygen therapy, the facility did not have a physician's order for continuous oxygen, which is required to specify the liter flow and method of administration. The resident was documented as receiving oxygen on several occasions, but there was no evidence of a physician's order for continuous oxygen therapy. The deficiency was identified following a community-reported complaint that the resident was transported to the hospital due to breathing difficulties. Interviews with facility staff, including a Licensed Practical Nurse, a Registered Nurse, and the Director of Nursing Services, confirmed the absence of a physician's order for continuous oxygen. The Director of Nursing Services acknowledged the need for such an order and the requirement to document the resident's oxygen saturation level every shift, but could not explain why the order was not in place.
Failure to Maintain Accurate Oxygen Therapy Records
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with professional standards for a resident receiving oxygen therapy. The resident, who was readmitted to the facility with diagnoses including congestive heart failure and shortness of breath, was documented in hospital records as being on 3 liters of oxygen at baseline. However, the facility's records only showed a physician's order for oxygen at 1 liter via nasal cannula as needed, with no evidence of an order for continuous oxygen therapy. Progress notes indicated the resident was receiving varying levels of oxygen on multiple dates, but these were not documented in the Medication Administration Record. Interviews with staff revealed inconsistencies in the documentation of the resident's oxygen therapy. A Licensed Practical Nurse confirmed that the resident utilized oxygen continuously, receiving between 1-3 liters. The Director of Nursing Services acknowledged the expectation for staff to document oxygen administration and the resident's oxygen saturation level every shift, but was unable to provide evidence of complete and accurate records. This lack of documentation and adherence to professional standards led to the deficiency finding.
Failure to Provide Hip Protectors Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that a resident, identified as a high fall risk, was provided with hip protectors as an intervention to prevent accidents. The resident, who had severe cognitive impairment and a history of falls, was ambulating with staff assistance when they tripped and fell, resulting in a right femur fracture. A physician's order was in place to encourage the use of hip protectors at all times, except during personal care, but the resident was not wearing them at the time of the fall. The incident report and staff interviews revealed that the hip protectors were marked as unavailable by an LPN on the shift when the fall occurred. The LPN could not recall if the resident was wearing the protectors and acknowledged that they were not provided due to being soiled. The Director of Nursing Services was unable to provide evidence that the hip protectors were offered or refused by the resident, and there was no documentation in the progress notes indicating that the resident declined to wear them. This oversight led to the resident sustaining a broken hip.
Failure to Assess and Document Use of Alarms as Restraints
Penalty
Summary
The facility failed to ensure that residents are free from physical restraints that are not required to treat medical symptoms, specifically in the case of a resident who was using two alarms as a fall intervention. The resident, who was admitted in September 2021 with diagnoses including difficulty walking and repeated falls, was found to have two alarms engaged while sitting in a wheelchair. These alarms were intended to prevent the resident from getting out of the chair, and the resident expressed dislike for them. The alarms were not easily removable by the resident, indicating a potential restraint situation. The facility did not provide evidence of an assessment for the use of these alarms or any ongoing evaluation of their necessity and potential adverse effects. Interviews with staff revealed a lack of awareness regarding any assessments performed for the alarms' use. The Administrator and Assistant Director of Nursing acknowledged the use of the alarms but could not demonstrate that they did not restrict the resident's movement or that they were the least restrictive intervention. This lack of documentation and assessment led to the deficiency noted by the surveyors.
Failure to Conduct Comprehensive and Significant Change Assessments
Penalty
Summary
The facility failed to conduct comprehensive assessments using the Resident Assessment Instrument (RAI) for five out of six residents reviewed. These assessments are required to include both the Minimum Data Set (MDS) and the Care Area Assessment (CAA) process, as well as care planning. The MDS is a preliminary assessment that identifies potential resident problems, while the CAA process provides further assessment of triggered areas. For residents with IDs 7, 25, 39, 53, and 89, the facility did not complete the necessary CAA documentation, which should include information on complicating factors, risks, and any referrals for the care areas. The Minimum Data Set Coordinator acknowledged the absence of CAA notes for these residents during a surveyor interview. Additionally, the facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who was admitted to hospice services, indicating a significant change in health status. According to the MDS 3.0 Resident Assessment Instrument Manual, an SCSA is required when a resident elects the hospice benefit. The record review for this resident, identified as Resident ID #50, did not reveal evidence of a completed SCSA after the resident's admission to hospice services. The Assistant Director of Nursing Services (ADNS) confirmed during an interview that a significant change assessment should have been completed. These deficiencies highlight the facility's failure to adhere to the required assessment protocols, which are crucial for identifying and addressing the needs of residents. The lack of comprehensive assessments and significant change assessments can impede the development of individualized care plans aimed at promoting residents' highest practicable level of functioning.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure accurate assessments for several residents, leading to discrepancies in their medical records. Resident ID #8, who was readmitted with a diagnosis of repeated falls, was inaccurately assessed in the Minimum Data Set (MDS) as using bed and chair alarms less than daily, despite a physician's order indicating daily use. Similarly, Resident ID #19, diagnosed with nicotine dependence, was incorrectly documented as not using tobacco in the MDS, although the care plan indicated the resident was an independent smoker. Further inaccuracies were found with Resident ID #25, who was admitted with a diagnosis of MRSA. Despite two consecutive negative MRSA screenings, the resident was still coded as having an active MDRO in the MDS. Additionally, Resident ID #56, admitted with urine retention, was inaccurately documented as having an indwelling catheter in two MDS assessments, even though the catheter had been removed. The MDS Coordinator acknowledged these inaccuracies, and the facility's administration could not provide evidence of accurate MDS assessments for these residents.
Failure to Implement Infection Control for MDRO
Penalty
Summary
The facility failed to maintain an infection prevention and control program to prevent the transmission of communicable diseases and infections, specifically concerning Multi-drug Resistant Organisms (MDRO). The deficiency was identified for one resident who was readmitted to the facility with a diagnosis of MRSA colonization. The facility's policy required Enhanced Barrier Precautions for residents with MDRO colonization, which includes the use of gowns and gloves during high-contact care activities. However, the facility did not adhere to these precautions for the resident in question. The resident's care plan indicated a goal to prevent the spread of MRSA, yet the facility did not conduct timely MRSA screenings as per their policy. The resident tested positive for MRSA in the nares in 2021, and a subsequent MRSA screen was delayed until 2024, which resulted negative. Despite this, there was no evidence of two consecutive negative MRSA cultures before removing the resident from Contact or Enhanced Barrier Precautions. Observations during the survey confirmed that the resident was not on the required precautions, and the facility staff could not provide evidence of maintaining an effective infection prevention and control program.
Failure to Transcribe and Execute Verbal Orders for Post-Fall Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The resident, who was on an anticoagulant medication, experienced an unwitnessed fall with a head strike and subsequently developed a headache. Although the Nurse Practitioner was notified of the fall and aware of the resident's anticoagulant use, she was not informed about the resident's headache. She had given a verbal order for neurological assessments and vital signs to be completed every shift for 72 hours, but this order was not transcribed into the resident's record. Further review revealed that there was no evidence that the neurological assessments and vital signs were completed as per the Nurse Practitioner's verbal order. The Assistant Director of Nursing confirmed the lack of documentation and stated that residents with a head strike while on an anticoagulant should be sent to the emergency room for evaluation. This oversight in communication and documentation led to a deficiency in the care provided to the resident.
Failure to Provide Appropriate Mechanical Soft Diet
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of a resident on a mechanical soft diet. The resident, who was admitted with a diagnosis of dysphagia, experienced difficulty swallowing during a meal, which led to a diet downgrade to mechanical soft as per a physician's order. Despite this, the resident was served inappropriate food items, such as whole sausage links and bacon, which are not suitable for a mechanical soft diet. Surveyor observations and interviews revealed that the resident was served whole sausage links and bacon on separate occasions, which the resident found difficult to eat. Staff members, including a registered nurse and a cook, acknowledged that these food items were not appropriate for the resident's dietary needs. The Assistant Director of Nursing Services also confirmed that the resident should not have received these items and was unable to provide evidence that the food was prepared according to the resident's individual needs.
Latest citations in Rhode Island
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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