Berkshire Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Providence, Rhode Island.
- Location
- 455 Douglas Avenue, Providence, Rhode Island 02908
- CMS Provider Number
- 415119
- Inspections on file
- 58
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Berkshire Place during CMS and state inspections, most recent first.
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 provide ordered catheter care for three residents with Foley and suprapubic (SP) catheters. One resident with neurogenic bladder had physician orders for monthly Foley changes and evaluation by urology when urine became cloudy and blood-tinged, but records showed no Foley exchange after a prior hospital procedure and no evidence that urology was contacted, despite later emergency room findings of a crusted catheter, meatal erosion, urinary retention, and foul-smelling urine. A second resident with malignancies and an SP catheter had an order for urology follow-up and a documented plan for an SP exchange at four weeks in the facility, yet records showed no SP exchange after the last urology visit, even though nursing staff were reportedly competent to perform SP exchanges. A third resident with flaccid neuropathic bladder and an SP catheter missed a scheduled urology appointment for an SP exchange, and the facility could not show any subsequent urology visits or SP catheter exchanges as ordered.
A resident with dementia and anxiety disorder, who was cognitively intact, threatened to physically harm another resident and was sent to the ER for evaluation. The DON acknowledged that this incident, which met the criteria for abuse reporting, was not reported to RIDOH as required by state law and facility policy.
Surveyors found that medications, including Trelegy Ellipta inhalers, Morphine Sulfate, and Lorazepam Intensol, were opened and not dated, and that Lorazepam was not refrigerated as required. Staff acknowledged these lapses in medication storage and labeling during interviews.
A resident with schizophrenia and moderate cognitive impairment, who was dependent on staff for supervision, successfully eloped from the facility after repeatedly expressing a desire to leave. Despite prior documentation of elopement risk and a physician order restricting leave, the facility did not reassess the resident's risk or update the care plan after the incident, and failed to complete required assessments or documentation.
A facility failed to notify a resident and their representative of a transfer or discharge, including the reasons for the move, in writing and in a language and manner they understand. The resident, with severe cognitive impairment and diagnoses of violent behaviors and dementia, was transferred to the hospital following an alleged interaction and subsequently discharged. The facility could not provide evidence of the required notification during a surveyor interview.
A facility failed to provide a resident or their representative with written notification of the bed-hold policy during a hospital transfer. The resident, with severe cognitive impairment and a history of violent behaviors, was transferred following an interaction with another resident. The facility's Administrator and DON could not provide evidence of the required notification.
A facility failed to allow a resident to return after hospitalization, violating bed-hold policy. The resident, admitted since 2019 with dementia and violent behaviors, was sent to the hospital for evaluation after an incident. Diagnosed with COVID-19 and a UTI, the resident was discharged without a 30-day notice. The Administrator and DON confirmed the decision not to allow the resident's return, despite the lack of documentation supporting this action.
The facility was found deficient in food safety standards as hot food items were served below the required temperature, and there was no evidence of reheating to meet policy standards. Additionally, a dietary aide was observed handling equipment in the kitchen without a hair restraint, contrary to facility policy. These issues were identified during a survey following a complaint about food temperatures and staff not wearing hairnets.
The facility failed to provide food and drinks at an appetizing temperature for several residents. A community complaint highlighted that hot food items were served cold. Residents reported ongoing issues with cold food, leading some to source meals externally or reheat them personally. A test tray confirmed that food temperatures were below the facility's policy requirements, with staff acknowledging the failure to maintain appropriate temperatures.
A resident with moderately impaired cognition allegedly touched another resident with severely impaired cognition inappropriately in a sunroom. The incident was witnessed by a cognitively intact resident who intervened and reported it to staff. The police were involved, and the resident was arrested for second-degree sexual assault.
Multiple residents experienced significant medication errors due to transcription mistakes and failure to follow physician orders. A resident with hypertension received Lasix despite an order to hold it, while another with gastric ulcer and diabetes received incorrect dosages of metronidazole and missed metformin doses. A resident with seizures missed doses of Valproic Acid, and a resident with heart failure received an incorrect total dose of Lasix. Staff acknowledged these errors during surveyor interviews.
A facility failed to create a comprehensive care plan for a resident identified as a smoker, despite assessments confirming nicotine dependence. The DON acknowledged the oversight during an interview.
A resident with severe morbid obesity and muscle weakness, dependent on staff for bathing, did not receive scheduled showers as ordered. Despite a care plan and physician's order for biweekly showers, staff interviews and surveyor observations revealed the resident had not been showered since May. The primary NA admitted to not providing showers, and facility management could not provide evidence of compliance with the care plan.
A facility failed to document the administration of oxygen for a resident with lung cancer and pneumonia, as required by their policy and professional standards. Despite physician orders specifying oxygen flow rates and conditions, records did not consistently reflect the amount of oxygen administered, even when the resident was observed on oxygen. The resident's physician expected proper documentation, highlighting a deficiency in respiratory care practices.
The facility failed to follow physician's orders for two residents. One resident did not receive scheduled laboratory tests for Valproic Acid levels, and another resident did not have daily weights recorded or a psychiatric consult completed. The DNS could not provide evidence of these actions during the surveyor interviews.
The facility failed to maintain accurate medical records for two residents. One resident did not receive a shower and wound treatment as documented, and another resident did not have a psychiatric evaluation as ordered. Staff interviews confirmed the inaccuracies in documentation.
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 Provide Ordered Foley and Suprapubic Catheter Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services related to urinary catheter care for three residents with indwelling catheters. One resident with a Foley catheter was admitted with urinary retention and neurogenic bladder and had physician orders for monthly Foley catheter changes and as-needed changes. Treatment Administration Records showed the monthly change order documented as not applicable or refused, and an order directing the primary team to determine if the Foley should be exchanged by urology for discolored, cloudy, and blood-tinged urine was signed as completed. However, there was no evidence that urology was contacted or that an appointment was scheduled, and the Foley catheter had not been exchanged since a hospital procedure months earlier. A community complaint later alleged that this resident arrived at the emergency room with a crusted Foley catheter, erosion of the urinary meatus, significant urinary retention, and foul-smelling urine. The deficiency also includes failure to follow physician orders for suprapubic (SP) catheter exchanges for a second resident with external genitalia, head, and neck malignancies. This resident had a care plan requiring SP catheter changes per physician orders and an order to call and set up an appointment with urology for an SP catheter exchange, which was documented as completed daily on the Treatment Administration Records. A continuity of care document showed that urology had exchanged the SP catheter and indicated that the next SP exchange was due in four weeks at the facility. Record review did not show any evidence that the SP catheter had been exchanged since that urology visit, despite the nurse practitioner’s expectation that the exchange would occur in the facility if not done by urology and the ADNS’s statement that nursing staff were competent to perform SP tube exchanges. For a third resident with a flaccid neuropathic bladder and an SP catheter, the care plan required SP catheter changes per physician orders, and an order specified that SP catheter exchanges were to be completed at urology. A continuity of care document showed that urology had exchanged the SP catheter and scheduled a follow-up appointment for an annual check-up and SP catheter exchange. The urology receptionist reported that the resident did not attend the scheduled follow-up appointment and had not been seen since the prior exchange. The ADNS was unable to provide evidence that the resident had any urology appointments after that date or that the SP catheter had been exchanged according to the physician’s order.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported to the Rhode Island Department of Health (RIDOH) as required by state law and facility policy. Specifically, a resident with diagnoses including dementia and anxiety disorder, who was cognitively intact according to a recent assessment, threatened to physically harm another resident. This incident was documented in a progress note, and the resident was subsequently sent to the emergency room for evaluation and admitted. Despite the facility's policy requiring immediate reporting of suspected abuse to the Director of Nursing and RIDOH, the Director of Nursing acknowledged during a surveyor interview that the incident was not reported to RIDOH. The failure to report the allegation of abuse in a timely manner constituted noncompliance with both state regulations and the facility's own procedures.
Failure to Properly Store and Label Medications
Penalty
Summary
Surveyor observations revealed that drugs and biologicals were not stored and labeled according to professional standards in two of four medication carts inspected. Specifically, two Trelegy Ellipta inhalers were found opened and undated, despite manufacturer instructions requiring disposal six weeks after opening. Additionally, Morphine Sulfate and Lorazepam Intensol oral suspension were found opened and undated, with the Lorazepam not stored in the required refrigerated conditions. The pharmacy label and manufacturer instructions for these medications specify discard dates and storage requirements that were not followed. Staff present during these observations, including a Certified Medication Technician, an LPN, and an RN, acknowledged the deficiencies when interviewed by surveyors. The Director of Nursing Services also confirmed that medications should be dated when opened and that Lorazepam should be refrigerated. These findings were consistent with a community complaint alleging improper medication storage and administration.
Failure to Assess and Intervene After Resident Elopement
Penalty
Summary
A resident with a diagnosis of schizophrenia and moderately impaired cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 9 out of 15, was admitted to the facility and required supervision for ambulation and dressing. Despite a physician order prohibiting the resident from taking a leave of absence, and documentation that the resident was an elopement risk and required supervision for smoking, the facility failed to reassess the resident's elopement risk after multiple documented behaviors indicating a desire to leave, including repeated requests to go home and expressing a strong desire to return home. The resident ultimately left the facility unsupervised and traveled to a previous residence, with the facility only learning of the elopement after being contacted by the other location. Following the resident's return, the facility did not perform an elopement assessment or develop a care plan with interventions to minimize further risk, as required by its own policy. Progress notes and staff interviews confirmed that no elopement evaluation or AMA discharge documentation was completed after the incident, and the Director of Nursing and Administrator acknowledged these omissions. The facility's failure to identify and address the resident's increased risk for elopement, and to implement appropriate interventions after the event, resulted in a deficiency related to inadequate supervision and accident prevention.
Failure to Notify Resident and Representative of Transfer or Discharge
Penalty
Summary
The facility failed to notify a resident and their representative of a transfer or discharge, including the reasons for the move, in writing and in a language and manner they understand. This deficiency was identified for a resident who was transferred to the hospital and subsequently discharged from the facility. The resident, who had been admitted in July 2019 with diagnoses of violent behaviors and dementia, was involved in an alleged resident-to-resident interaction that led to their transfer to the emergency room on January 14, 2025. The record review did not reveal any evidence that the facility provided the required notification to the resident or their representative. During an interview with the Administrator and the Director of Nursing, they were unable to provide documentation that the necessary notifications were made. The resident's severe cognitive impairment, as indicated by a Quarterly Minimum Data Set Assessment, further underscores the importance of proper communication with their representative.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification to a resident or their representative regarding the bed-hold policy during a transfer to the hospital. The deficiency was identified through a record review and staff interviews, which revealed that the facility did not provide the required written notice specifying the duration of the bed-hold policy at the time of the resident's transfer. This oversight was noted for a resident who was transferred to the emergency room following an alleged interaction with another resident. The resident, who was admitted to the facility in July 2019 with diagnoses of violent behaviors and dementia, was documented as having severe cognitive impairment. The complaint, submitted to the Rhode Island Department of Health, alleged that the resident was not allowed to return to the facility and did not receive a 30-day notice as required. During an interview, the facility's Administrator and Director of Nursing were unable to provide evidence of the required written notification to the resident or their representative regarding the bed-hold policy.
Facility Fails to Allow Resident Return Post-Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after a hospitalization, violating the bed-hold policy. The resident, who had been living in the facility since July 2019, was transferred to the hospital for a psychological evaluation following an alleged interaction with another resident. The hospital diagnosed the resident with COVID-19 and a urinary tract infection, which can cause agitation in the elderly. Despite these circumstances, the facility discharged the resident on the same day as the hospital transfer, without providing the required 30-day notice. Surveyor observations confirmed that the resident's room was vacant following the transfer. During interviews, the Administrator and the Director of Nurses admitted that they decided not to allow the resident to return to the facility. This decision was made despite the absence of documentation supporting the resident's discharge or any evidence that the resident was given the opportunity to return after hospitalization, as required by regulations.
Deficiencies in Food Safety and Hair Restraint Compliance
Penalty
Summary
The facility failed to adhere to professional standards of food service safety during meal preparation, storage, and distribution. During a surveyor observation, it was noted that the temperatures of hot food items on the steam table were below the required holding temperature of 135 degrees Fahrenheit. Specifically, mashed potatoes were at 129.2 F, chicken at 128.3 F, and burger patties at 125.4 F. The facility's policy mandates that if food is below 135 F, it should be reheated to at least 165 F for a minimum of 15 seconds before serving. However, there was no evidence that these food items were reheated to meet the policy requirements. The Food Service Director acknowledged that the food should have been reheated according to the facility's policy. Additionally, the facility did not comply with the Rhode Island Food Code regarding the use of hair restraints in the kitchen. During an observation, a dietary aide was seen handling equipment in the main kitchen without wearing a hair restraint, which is against the facility's policy. The Food Service Director confirmed that all staff are expected to wear hair restraints while working in the kitchen. These deficiencies were identified during a survey following a community-reported complaint about food being served at unappetizing temperatures and staff not wearing hairnets.
Failure to Maintain Appropriate Food Temperatures
Penalty
Summary
The facility failed to provide food and drinks that are palatable, attractive, and at an appetizing temperature for four out of five residents reviewed. A community complaint was submitted to the Rhode Island Department of Health, alleging that hot food items were being served cold and at an unappetizing temperature. The facility's policy requires hot foods on room trays to be at 120°F or greater to promote palatability. However, surveyor interviews with residents revealed ongoing issues with cold food. Resident ID #2, admitted in September 2021 with type II diabetes mellitus, reported that hot food items have always been cold since admission. Resident ID #3, admitted in October 2024 with hypertension, stated that the food served within the last week was cold and not palatable, leading to sourcing meals from outside the facility. Resident ID #4, readmitted in August 2024 with depression, mentioned having to microwave food daily due to it being served cold. Resident ID #5, admitted in September 2024 with gastro-esophageal reflux disease, refused to eat breakfast because it was not hot and had to heat the food personally. A test tray ordered by the Unit Manager, Staff A, showed that the food temperatures were below the facility's policy requirements. The mashed potatoes were at 112.7°F, chicken at 106.1°F, and vegetables at 117.8°F. Staff A acknowledged that the food failed to hold the temperature from the steamer and expected temperatures closer to 135°F. The Food Service Director also expected the food to be at least 120°F or higher, per the facility policy. These findings indicate a failure to maintain appropriate food temperatures, leading to dissatisfaction among residents and non-compliance with the facility's policy on food service temperatures.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, as evidenced by an incident involving two residents. Resident ID #1 reported that Resident ID #2 entered their room and joined them in bed without consent. Further allegations were made that Resident ID #2 sat on Resident ID #1's face while fully clothed, leading Resident ID #1 to retaliate by touching Resident ID #2's genitals. Resident ID #1 was admitted with mild neurocognitive disorder and had a BIMS score indicating moderately impaired cognition. Resident ID #2, with a history of dementia and schizophrenia, had a BIMS score indicating severely impaired cognition, making it difficult for surveyors to interview them. The incident was witnessed by another resident, Resident ID #4, who reported seeing Resident ID #1 touch Resident ID #2's thigh and move their hand towards the upper thigh in the sunroom. Resident ID #4, who had no cognitive impairments, intervened and reported the incident to the facility staff. The police were involved, and Resident ID #1 was arrested for second-degree sexual assault. The facility's failure to prevent this incident and protect the residents from abuse constitutes a deficiency in their care standards.
Medication Errors Affect Multiple Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting four out of nine residents reviewed. Resident ID #111, who was admitted with hypertension and acute kidney failure, received Lasix despite an order to hold the medication for three days due to lab results. The medication was administered on three consecutive days in error. Resident ID #136, with a history of gastric ulcer and diabetes mellitus, received an incorrect dosage and frequency of metronidazole due to a transcription error, and missed 34 doses of metformin because the order was not transcribed. The errors were acknowledged by the staff involved during surveyor interviews. Resident ID #162, admitted with seizures, did not receive Valproic Acid on two occasions, and the provider was not notified of the missed doses. Staff acknowledged the oversight during interviews. Resident ID #186, with abnormal blood chemistry and heart failure, received an incorrect total dose of Lasix due to a failure to hold the 20 mg dose as ordered and an error in administering both 20 mg and 40 mg doses on the same day. The staff involved confirmed the administration errors during surveyor interviews, and the Director of Nursing Services was unable to provide evidence that the Lasix order was followed correctly.
Failure to Develop Comprehensive Smoking Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident identified as a smoker. The resident was admitted to the facility in May 2024 with a diagnosis that included nicotine dependence. A smoking assessment was completed upon both admission and re-admission, indicating the resident is a smoker. However, the facility did not create a comprehensive care plan for smoking as required by their policy. During an interview, the Director of Nursing Services acknowledged the resident's smoking status and the absence of a comprehensive care plan addressing this issue.
Failure to Provide Scheduled Showers to Dependent Resident
Penalty
Summary
The facility failed to provide necessary services to a resident who was unable to carry out activities of daily living, specifically regarding scheduled showers. The resident, admitted in June 2023 with severe morbid obesity and generalized muscle weakness, was dependent on staff assistance for bathing and showering. A care plan dated January 2024 confirmed the resident's dependency on staff for self-care and mobility, including showers. A physician's order from July 2024 specified biweekly showers on Mondays and Thursdays during the day shift. However, surveyor observations on July 24 and 25, 2024, noted a strong odor of urine in the resident's room, and the resident reported not having received a shower since moving to the unit in May 2024. Interviews with staff revealed further deficiencies in care. The resident's primary Nursing Assistant (NA), Staff B, admitted to not providing the resident with a shower since May 2024, despite being assigned to the resident on specific dates when showers were ordered. Staff B also acknowledged that the shower chair was not broken, contradicting the reason given to the resident for not receiving showers. Additionally, the unit manager, an LPN, and the Director of Nursing Services were unable to provide evidence that the resident received showers as ordered, indicating a systemic failure in adhering to the care plan and physician's orders for the resident's hygiene needs.
Failure to Document Oxygen Administration
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident with a history of lung cancer, shortness of breath, and pneumonia. The deficiency was identified through surveyor observation, record review, and staff interviews. According to the facility's policy and the Lippincott Manual of Nursing Practice, documentation of oxygen administration should include the date, time, amount, and method of administration, as well as the resident's condition before and after therapy. However, the facility's records did not consistently document the amount of oxygen administered to the resident on several occasions, despite the resident being observed on oxygen during surveyor visits. The resident had a physician's order for oxygen administration, specifying a flow rate of 2-4 liters via nasal cannula, with instructions to titrate as needed to maintain pulse oximetry levels above 88% on room air. Despite these orders, the facility's Treatment Administration Record for July 2024 failed to document the administration of oxygen on specific dates, as required by the facility's policy. During an interview, the resident's physician expressed the expectation that staff should document the date, time, and amount of oxygen administered each time it is given. This lack of documentation represents a failure to adhere to the facility's policy and professional standards of practice for respiratory care.
Failure to Follow Physician's Orders for Laboratory Tests and Consults
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice by not following physician's orders for two residents. Resident ID #162, who was admitted with a seizure disorder, had a physician's order for Valproic Acid and required bloodwork, including a comprehensive metabolic panel (CMP) and Valproic Acid level, every six months starting on 6/12/2024. However, the laboratory results for these tests were not obtained as ordered, and the Director of Nursing Services (DNS) could not provide evidence of the completed laboratory work during the surveyor interview. Resident ID #241, admitted with cirrhosis of the liver, ascites, and a history of depression, had a physician's order for daily weights and a psychiatric consult. The resident's weights were not recorded on two specific dates, and there was no evidence that the psychiatric consult was completed. The DNS acknowledged the failure to obtain daily weights and could not provide evidence of the psychiatric evaluation during the surveyor interview. The resident's physician expressed the need for a psychiatric evaluation before starting any medications.
Inaccurate Medical Record Documentation for Resident Care
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with professional standards for two residents. For Resident ID #111, discrepancies were found in the documentation of shower schedules and wound treatment. The resident was admitted with diagnoses including morbid obesity and generalized muscle weakness. The physician's orders specified a weekly shower schedule and the application of a skin protectant cream to a wound on the left posterior thigh. However, the Nursing Assistant assignment log showed a different shower schedule, and the Treatment Administration Record inaccurately indicated that the resident received a shower and wound treatment on a specific date. Interviews with the Nursing Assistant and Registered Nurse involved confirmed that the documented care was not provided. For Resident ID #241, the facility failed to provide evidence of a psychiatric evaluation as ordered. The resident, admitted with cirrhosis of the liver, ascites, and a history of depression, had a physician's order for a psychiatric consultation. Although a form indicated that the psychiatric provider signed off on completing the consult, there was no evidence that the evaluation occurred. An interview with the Director of Nursing Services revealed the absence of documentation to support that the psychiatric evaluation was conducted, and subsequent communication with the psychiatric provider confirmed that the evaluation was not completed.
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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