Elmhurst Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Providence, Rhode Island.
- Location
- 50 Maude Street, Providence, Rhode Island 02908
- CMS Provider Number
- 415084
- Inspections on file
- 68
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 16 (1 serious)
Citation history
Health deficiencies cited at Elmhurst Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with dementia, severe cognitive impairment (BIMS 3/15), poor safety awareness, and high elopement risk, who self-propelled rapidly in a wheelchair and wore a wander guard, was inadequately supervised on a secured unit. The resident wheeled to a stairwell exit door, held the fire bar until it released, exited into the stairwell, and fell down a flight of stairs while in the wheelchair. The stairwell door alarm sounded but was not loud enough to be heard by staff in common work areas such as the shower room, dining room, and a nearby office, and individuals in an adjacent medical office, rather than facility staff, reported hearing the alarm and subsequent noise. The resident was found on the stairwell landing with a head injury and was later diagnosed via CT with a subdural hematoma and subarachnoid hemorrhage, demonstrating a breakdown in elopement prevention and supervision systems.
A cognitively intact resident with type 2 DM had a weekly Mounjaro injection ordered and four pens supplied, which the facility counted in the narcotic book due to cost. An LPN documented that a scheduled dose was administered, but two nurses later confirmed that the narcotic count and physical inventory still showed all four pens present, contradicting the MAR. The LPN later claimed to have given the dose and entered a late narcotic-book entry, yet could not explain how the count remained unchanged or then dropped from four to three pens. Subsequent review by the ADON revealed conflicting documentation and an unresolved discrepancy in the medication count, leaving one Mounjaro pen unaccounted for and constituting misappropriation of the resident’s medication under facility policy.
A cognitively intact resident with type 2 DM, ordered weekly Mounjaro injections, reported not receiving a scheduled dose even though an LPN had documented it as given. Narcotic count records showed that the number of Mounjaro pens in the refrigerator remained unchanged after the date the dose was charted as administered, and only later decreased, creating a discrepancy the LPN could not explain. The DON, ADON, and Administrator tracked the counts and identified the inconsistency but were unable to show that this allegation of potential misappropriation or medication diversion was reported to the State Survey Agency as required.
A resident with type 2 DM, who was cognitively intact, reported not receiving a scheduled Mounjaro injection even though an LPN documented the dose as given on the MAR. Pharmacy delivery records and the narcotic count book showed that all Mounjaro pens remained in the refrigerator and on the count for several days, contradicting the MAR entry. An RN supervisor and another staff member verified that the narcotic count and physical inventory had not changed, and the ADON later found that the count did not decrease until days after the documented administration. The LPN admitted entering the narcotic record late, despite facility policy requiring immediate documentation, and leadership could not substantiate that the recorded administration actually occurred.
A resident with dementia and heart failure was discharged home with medically necessary skilled nursing and therapy ordered, but the facility failed to communicate to the home care agency that the assigned PCP was a new provider who would not sign home health orders until seeing the resident. The home care agency, after an initial assessment, learned the PCP would not sign and repeatedly called the facility requesting the facility MD’s signature so services could begin, but the calls were not returned for an extended period. The resident’s family also made multiple unsuccessful attempts to reach the social worker, who had previously stated the new PCP would sign the orders but could not provide evidence of this. The facility’s lack of communication about the PCP status and failure to respond to the agency’s and family’s calls resulted in the resident not receiving the ordered home health services after discharge.
A resident with anxiety, depression, and heart failure, who required significant assistance with ADLs, reported being treated rudely by two nursing assistants, including being spoken to with explicit language when requesting their phone. The incident was corroborated by a roommate and acknowledged by one staff member, who received a verbal warning for disrespectful conduct. The resident expressed ongoing fear of the night shift staff, and facility leadership could not provide evidence that the resident was treated with dignity and respect.
A resident admitted with sepsis and a surgical wound did not receive prescribed wound care for several days after admission, despite clear instructions in the hospital discharge documents. Staff interviews confirmed that the wound care orders were not implemented until days after admission, and the DON could not provide evidence of timely treatment.
Surveyors found that thirty-four thawed nutritional supplement shakes in the main kitchen refrigerator were not labeled with a use-by date as required by the manufacturer's instructions, and the Food Service Director confirmed the omission. Additionally, the ice machine's dispenser shield had a visible accumulation of a pink wipeable substance, which was acknowledged by the Regional Food Service Director.
A working call system was not available in each resident's bathroom and bathing area, preventing residents from being able to summon assistance when needed.
A resident with advanced dementia and bowel incontinence was escorted out of the facility by a Certified Medication Technician without receiving necessary incontinence care, resulting in the resident being visibly soiled when handed over to a family member for a hospital visit. The DON confirmed that the expectation was for residents to be clean before leaving, but no evidence was provided that this standard was met.
Two residents did not receive care in accordance with professional standards: one was not provided with a physician-ordered fluid intake plan following a urology consult, and another with dysphagia received paper products on their meal tray despite dietary restrictions. Staff acknowledged the lapses, and orders were not properly followed or communicated.
A resident with CHF was admitted with a physician's order for daily weights, but the order was not implemented until over two weeks later, and daily weights were not documented on multiple days. Interviews with the NP and DON confirmed the lack of evidence for daily weight monitoring as required by the care plan and physician's order.
Surveyors observed three medication errors out of 28 opportunities, resulting in a medication error rate over 10%. Errors included an LPN preparing an unmeasured dose of liquid Keppra instead of the ordered tablet, another LPN failing to mix GlycoLax powder with the prescribed amount of fluid, and a resident self-administering Fluticasone nasal spray in excess of the ordered dose without proper authorization for self-administration.
A resident with dementia and impaired cognition was physically struck in the face by another cognitively impaired resident with a history of agitation when others entered his room. Despite two prior incidents of verbal aggression under similar circumstances, staff did not implement new interventions, leading to a physical altercation that caused a bloody nose and facial bruising.
A resident with multiple medical conditions left the facility after informing the NP of their intent to leave against medical advice. Although the NP documented the resident was medically cleared, there was no evidence of a physician's discharge order, interdisciplinary discharge plan, notice of discharge, discharge summary, or medication reconciliation. Staff confirmed that required discharge procedures and documentation were not completed, and the resident reported not receiving paperwork, medications, or referrals upon leaving.
A resident with multiple medical conditions and intact cognition left the facility without staff knowledge or completion of required discharge procedures. Staff were aware of the resident's intent to leave and observed the resident preparing to depart, but did not ensure the resident remained until proper discharge planning was completed. The facility did not notify law enforcement or complete necessary documentation, including discharge orders and medication reconciliation, as required by policy.
A resident left the facility without staff knowledge, and the absence was not discovered for several hours. Staff assumed the resident had been discharged due to missing belongings and prior statements, but there was no documentation or evidence of a safe discharge, nor were medications or homecare services provided. Facility leadership could not confirm when the resident left or provide discharge records.
A resident with multiple diagnoses and intact cognition left the facility in the morning, but an LPN inaccurately documented administration of a scheduled Acetaminophen dose later that day. The LPN was unaware the resident had left and acknowledged the error after being interviewed. The DON confirmed that medications should only be documented as given if actually administered.
The facility failed to meet professional standards of quality in medication management and wound care. A resident with a baclofen pump did not receive proper wound care or monitoring, leading to a possible infection. Two residents received medications without following prescribed parameters, and another resident missed antibiotic doses without notifying the provider. Staff were unaware of necessary protocols for managing a baclofen pump.
The facility failed to schedule necessary medical consultations and adequately document wound care for several residents. A resident with dementia did not have a mammogram scheduled as ordered, and another with chronic kidney disease lacked a hematology consult. A resident with a duodenal ulcer did not receive a GI consult, and a resident with MS missed an ENT follow-up. Additionally, wound care documentation was insufficient for a resident with multiple wounds, lacking details on wound size and condition.
A facility failed to complete necessary assessments and obtain informed consent for residents using bed rails, affecting multiple residents across all floors. Observations revealed that residents had bilateral bed rails without documented evidence of completed assessments, informed consent, or attempted alternatives. Interviews with staff confirmed these deficiencies, and the facility was unable to determine bed and rail compatibility to mitigate entrapment risks.
The facility failed to maintain an effective infection prevention and control program, as staff did not adhere to contact precautions for residents with infections. A resident with ESBL and another with RSV were observed with staff entering their rooms without wearing required PPE, despite clear signage. Additionally, a resident with a history of ESBL was not placed on necessary precautions, contrary to CDC guidelines.
A resident with hearing loss, relying on lip reading, faced communication barriers due to a mask mandate in the facility. The care plan initially failed to address the resident's communication needs, and incorrect information about the use of ASL was provided. The issue was identified during a survey, leading to the provision of a communication board and an updated care plan.
A facility failed to include PASARR recommendations in a resident's baseline care plan, overlooking the resident's need for lip reading due to hearing loss. This deficiency was identified when the resident struggled to communicate with a surveyor wearing a mask, as required due to a respiratory illness outbreak. The issue was only addressed after being highlighted by the surveyor.
A resident with end-stage renal disease did not receive prescribed Velphoro medication due to a communication failure at the facility. The medication was not administered on multiple occasions, and the facility failed to notify the physician or dialysis center about the missed doses until several days later. The dietician confirmed that a 90-day supply had been delivered, and the dialysis center could have provided the medication if informed.
A resident with end-stage renal disease did not receive their prescribed Velphoro medication due to the facility's failure to ensure its administration. Despite a physician's order and a 90-day supply being delivered, the medication was not given on multiple occasions. The facility did not effectively communicate with the pharmacy or dialysis center to address the issue.
A resident with dementia and legal blindness was not provided with a required scoop plate during a meal, leading to food spillage. The care plan and diet order specified the need for this adaptive equipment, but staff were unaware of the requirement. The Interim DON acknowledged the expectation for the resident to have the scoop plate.
A medication error occurred when a cancer drug intended for a resident with prostate cancer was mistakenly transcribed and administered to another resident with liver cancer for 13 days. The facility's staff, including LPNs, a Medication Technician, two NPs, and a Consultant Pharmacist, failed to verify the medication details and resident identity, leading to the administration of an unnecessary drug. This oversight placed the resident at risk for serious harm.
The facility failed to identify medication irregularities during monthly drug regimen reviews for two residents. A resident with liver cancer was incorrectly given Abiraterone Acetate, intended for prostate cancer, due to a transcription error. Another resident with C. diff did not receive the full course of Fidaxomicin due to a transcription error. The pharmacy consultant did not identify these issues during the reviews.
The facility failed to maintain an effective QAPI program for medication administration, leading to errors. A resident with liver cancer received prostate cancer medication due to a transcription error, and another resident with a bacterial infection did not receive the full course of antibiotics. The facility could not provide evidence of daily medication order audits as required by their QAPI plan.
A resident with C. diff was prescribed Fidaxomicin for 5 days, but the medication was transcribed for only 4 days, resulting in missed doses. Staff interviews revealed that the error was acknowledged, but the Nurse Practitioner was unaware of the incomplete course. Despite ongoing symptoms, the antibiotic treatment was not extended.
Two residents experienced medication errors due to transcription mistakes. A resident with liver cancer was mistakenly given Abiraterone Acetate, intended for another resident with prostate cancer, for 13 days. Another resident with a C. Diff infection was prescribed Fidaxomicin for five days but received it for only four days, missing two doses. These errors were acknowledged by the nursing staff.
The facility failed to provide sufficient nursing staff, resulting in delayed call light responses. A resident reported that staff often took 30 minutes to 1 hour to respond. A surveyor observed a 36-minute delay in answering a call light. An LPN acknowledged the delay, and the administrator could not provide evidence of timely responses.
A resident with a history of diabetes and peripheral vascular disease developed infected foot ulcers and cellulitis due to the facility's failure to perform daily foot care and skin inspections as per the care plan. Additionally, the facility delayed administering prescribed antibiotics following the resident's hospital discharge, and did not schedule a timely follow-up with a vascular surgeon. These oversights led to a deterioration in the resident's condition, placing them at risk for serious harm.
A resident was administered Trazodone without consent, despite being cognitively intact and explicitly refusing the medication. The NP prescribed it as needed for anger, but it was given routinely, leading to the resident's lethargy. The DON confirmed the resident's right to be informed and consent to treatment was not upheld.
A resident at risk for pressure ulcers developed unstageable ulcers on both heels due to the facility's failure to implement timely interventions and adhere to care plans. Despite the resident's willingness to have their feet offloaded, surveyors observed multiple instances where the resident's heels were not offloaded as required. Staff interviews confirmed the lack of adherence to wound care orders, and the Director of Nursing Services could not provide evidence of necessary treatment and services being provided.
A resident who underwent knee surgery experienced unmanaged pain due to a delay in receiving prescribed oxycodone. Despite a physician's order, the medication was unavailable, and staff did not use the pyxis system to access it. The resident reported significant pain, which was only addressed after a nurse contacted the physician to resend the prescription.
The facility failed to manage psychotropic medications properly for two residents. One resident received Trazodone as a scheduled medication instead of as needed, contrary to the NP's order. Another resident's Risperidone dose was not reduced as recommended by a psychiatric evaluation, and the physician was unaware of the recommendation.
The facility failed to provide necessary toileting equipment for a resident post-knee surgery, leading to continence issues. Additionally, a urine analysis was delayed, resulting in a confirmed UTI. Two residents with suprapubic catheters experienced care deficiencies: one missed a urology appointment due to scheduling errors, and another did not have their catheter changed as ordered, leading to a hospital visit.
A resident with oral health issues and a care plan for dental care coordination did not receive timely assistance from the facility to obtain an oral surgeon consult for tooth extractions and dentures. Despite recommendations from a dental service provider, the facility failed to act until prompted by a surveyor, as confirmed by staff interviews and record reviews.
The facility failed to follow physician's orders for several residents, including not administering insulin and not conducting ordered lab tests. A resident with diabetes did not receive insulin or have their blood sugar rechecked as ordered. Another resident did not have a fecal occult blood test or urinalysis performed after blood was observed in the stool. Additionally, a resident with chronic kidney disease did not have a urinalysis obtained despite symptoms of a UTI. The facility also failed to implement a gradual dose reduction for a resident's medication, resulting in missed doses.
The facility failed to ensure that two LPNs had completed mandatory IV competency training before administering fluids and medications via a PICC line to a resident. The resident, who was receiving antibiotics through the PICC line, reported inadequate care, and was later sent to the hospital due to an occluded PICC line. The Director of Nursing could not provide evidence of the required training for the involved staff.
The facility failed to implement infection control measures for a resident diagnosed with MRSA. Despite a positive MRSA test result and the need for contact precautions, the resident was not placed on contact precautions, and staff were unaware of the resident's status. Even after corrective orders were issued, staff failed to comply with the required infection control protocols.
The facility failed to provide appropriate treatment and services for three residents with indwelling catheters, resulting in missed opportunities to measure and report urinary output, improper catheter management, and lack of documentation. The Director of Nursing Services acknowledged these deficiencies, indicating a systemic issue in the facility's catheter care practices.
The facility failed to maintain a sanitary and comfortable environment in 17 of 32 resident rooms observed. Deficiencies included gouges or missing and chipped paint, water-stained ceiling tiles, a ceiling tile with black wooly growth, stained privacy curtains, missing electrical outlet plate covers, missing paint on metal mirror frames, black tape on sink faucets, and black marring on floors. The Maintenance Director acknowledged all findings and agreed they were in need of repair or cleaning.
The facility failed to provide timely and appropriate treatment for a resident with pressure ulcers, as required by professional standards. Upon admission, the resident had three documented pressure injuries, but the facility's initial assessment was incomplete, and treatments were delayed or not documented. Interviews with staff confirmed these deficiencies.
The facility failed to supervise a resident with multiple sclerosis and depression, who was found with marijuana and smoking materials in their room, despite the facility's policy requiring supervision and storage of smoking materials at the nurses' station.
A resident's drug regimen was compromised when medications were left unattended on the bedside table, contrary to the facility's policy requiring staff to remain with residents until all medications are taken. The medications, which included Levetiracetam, Ibuprofen, and Baclofen, were not administered as scheduled.
A facility failed to store medications in locked compartments, leaving a resident's medication unattended on a bedside table. The medications, which included Levetiracetam, Ibuprofen, and Baclofen, were not administered as required by the facility's policy. The LPN responsible did not witness the resident take the medications and left them on the bedside table.
The facility failed to maintain an infection prevention and control program, leading to improper handling of a resident with MRSA and inadequate wound care practices for another resident. Staff did not implement required precautions or follow proper hygiene protocols, resulting in potential cross-contamination and increased infection risk.
Failure of Elopement Prevention and Supervision Leading to Stairwell Fall and Head Trauma
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an effective elopement prevention system for a resident on a secured unit who was known to be at high risk for elopement. The resident had dementia, a BIMS score of 3/15 indicating severe cognitive impairment, poor safety awareness, and the ability to self-propel rapidly in a wheelchair for at least 150 feet. An elopement assessment identified the resident as high risk and required the use of a wander guard bracelet on the right wrist. Despite these known risks and interventions, the resident was able to move independently throughout the secured unit and approach a stairwell exit door. On the day of the incident, the resident self-propelled in a wheelchair to the stairwell exit door on the secured unit, manipulated and held the fire bar until the door released, and exited into the stairwell. The resident then fell down approximately 10–12 stairs while still in the wheelchair, ultimately being found lying on the stairwell landing with the wheelchair on top. Staff interviews revealed that the stairwell door alarm did sound, but it was not loud enough to be heard by staff who were in typical work locations on the unit, including the shower room, dining room, and a nearby office. A nursing assistant reported only hearing the alarm after opening the shower room door, and both the supervising RN and the unit manager LPN reported not hearing the alarm from the dining room and office, respectively. Following the fall, the resident was assessed with a bump to the back of the head and was transferred by EMS to the hospital. The EMS report documented that staff from an adjacent medical office, not facility staff, heard the door open, the alarm sounding, subsequent noise, and someone screaming for help, and that the resident had fallen down 10–12 stairs. Hospital documentation and CT imaging showed the resident sustained a posterior scalp hematoma, tongue contusion, subdural hematoma, and right-sided subarachnoid hemorrhage, for which the resident was admitted. The facility’s failure to ensure that the secured unit door and alarm system effectively prevented or promptly alerted staff to the resident’s exit, combined with inadequate supervision of a known high-elopement-risk resident, resulted in this serious accident.
Unaccounted Mounjaro Dose and Misappropriation of Resident Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper administration, documentation, and accountability of a resident’s prescribed Mounjaro medication, resulting in an unaccounted-for dose that constituted misappropriation of resident property per facility policy. The resident, admitted with type 2 diabetes mellitus and documented as cognitively intact with a BIMS score of 15/15, reported not receiving a scheduled Mounjaro injection on a Friday, later identified as 3/13/2026. The resident stated that when this was reported to nursing staff two days later, staff responded that the dose had already been documented as given. The physician’s order directed that Mounjaro 5 mg be injected once every 7 days, and the facility’s practice, as described by the DNS, was to treat Mounjaro like a narcotic and count it in the narcotic book due to its high cost. Pharmacy and narcotic count records showed that four Mounjaro pens were delivered for the resident, and the MAR reflected that an LPN (Staff A) documented administration of a dose on 3/13/2026. However, on 3/15/2026, an RN (Staff C) and another nurse (Staff B) verified that the narcotic count book did not show removal or administration of a dose on 3/13/2026 and that all four pens were still present in the refrigerator, contradicting the MAR entry. During interview, Staff A claimed to have administered the dose on 3/13/2026 and stated he did not document removal in the narcotic book until 3/15/2026, but he could not explain how the count remained at four on 3/15/2026 or how it later decreased from four to three after his late entry. The ADON reported that on the morning of 3/16/2026 the narcotic count showed only three pens remaining and that, upon documenting a dose given that day, it was discovered that Staff A had entered documentation indicating administration on 3/13/2026 despite prior verification that all four pens were still in inventory. The DNS and Administrator confirmed they could not determine the location or disposition of the missing Mounjaro dose, and the unresolved discrepancy in count and documentation established that one prescribed pen was lost or otherwise unaccounted for.
Failure to Report Alleged Misappropriation of Mounjaro Injection
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of misappropriation and/or medication diversion of a resident’s prescribed Mounjaro injection to the State Survey Agency as required. A cognitively intact resident with type 2 diabetes mellitus, admitted in November 2025 and ordered to receive Mounjaro 5 mg subcutaneously once every 7 days, reported not receiving a scheduled Mounjaro injection on a Friday later identified as 3/13/2026. The resident stated that when this was reported to nursing staff on Sunday, staff responded that the medication had been documented as administered and identified an LPN as the nurse who signed for the dose. Facility records showed that four Mounjaro pens were delivered on 3/6/2026 and were being tracked in the narcotic count book due to their high cost. On 3/15/2026, after the resident’s report, nursing staff reviewed the narcotic count and confirmed that four pens remained in the refrigerator, consistent with the original delivery, and the narcotic record did not show removal of a dose on 3/13/2026. On 3/16/2026, the ADON confirmed three pens were present and documented, after administering a dose that day, and identified that the LPN had documented administration of a dose on 3/13/2026 that was not reflected in the narcotic count when reviewed on 3/15/2026. During a later interview, the LPN could not explain the discrepancy between the documented administration and the unchanged narcotic count through 3/15/2026, nor the subsequent decrease in count after his documentation. The DNS and Administrator were unable to provide evidence that this allegation of potential misappropriation was reported to the State Survey Agency.
Inaccurate and Delayed Documentation of Mounjaro Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate, complete, and timely medical records regarding the administration of Mounjaro, a medication prescribed for type 2 diabetes mellitus, for one cognitively intact resident. The resident, admitted with diagnoses including type 2 diabetes, had a physician’s order for Mounjaro 5 mg to be injected once every 7 days. The facility’s policy required medications to be documented immediately after administration, including reasons when a medication is withheld, not administered, or refused. The resident later reported not receiving the scheduled Mounjaro injection on 3/13/2026, despite documentation by an LPN that the dose had been administered on that date. Subsequent review of pharmacy delivery records and the narcotic count book showed that four Mounjaro pens were delivered on 3/6/2026 and that all four remained in the refrigerator and on the narcotic count from 3/6/2026 through 3/15/2026, indicating no dose had been removed or given during that period. A written statement from an RN unit supervisor documented that, after the resident’s report on 3/15/2026, two staff verified that both the narcotic count and physical inventory were unchanged, contradicting the MAR entry that a dose had been administered on 3/13/2026. The ADON later noted that the narcotic count did not decrease to three pens until 3/16/2026, and the LPN involved acknowledged that the narcotic book entry dated 3/13/2026 was actually completed on 3/15/2026, contrary to the facility’s requirement for immediate documentation. The DNS and Administrator were unable to provide evidence that the documentation supporting the 3/13/2026 Mounjaro dose was accurate or reliable, demonstrating conflicting and delayed documentation in the resident’s medical record.
Failure to Coordinate Home Health Orders and Communicate PCP Limitations at Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate communication of critical discharge information and coordination with a home care agency for a resident discharged with orders for skilled nursing and therapy. The resident, who had dementia, heart failure, and a BIMS score of 9 indicating moderate cognitive impairment, was admitted in January 2026 and discharged home on 2/15/2026 with medically necessary home health services ordered by the facility’s Medical Director. The facility’s social worker knew shortly after admission that the resident did not have a community PCP and arranged for a new PCP with an appointment scheduled for 2/26/2026. She also knew that this new PCP would not sign home health orders until the resident was seen in the office, but there was no documentation that this limitation was communicated to the home care agency. The home care agency accepted the referral for services to begin at discharge and conducted an initial assessment on 2/17/2026. Agency records showed that when staff contacted the new PCP for signed orders, they were informed the PCP would not sign until the resident’s 2/26/2026 office visit. The agency then called the facility on multiple occasions, beginning on 2/18/2026, leaving voicemails for the facility social worker to request that the facility’s Medical Director sign the home care orders so services could start before the PCP visit. Progress notes from the agency documented additional voicemails on 2/26/2026 and 2/27/2026, but the facility did not return these calls until 3/5/2026. As a result, the resident did not receive the ordered skilled nursing and therapy services after the initial home care assessment on 2/17/2026. The resident’s family member reported informing the facility a few days after admission that the resident had no PCP and later attempted to contact the social worker on three separate dates after discharge using the correct telephone number, without receiving a return call until 3/5/2026. The family member stated that the social worker had previously assured them that the new PCP had agreed to sign home care orders prior to the office visit, but the social worker could not provide evidence of such an agreement and denied receiving the calls, despite acknowledging the phone number used was correct. The Medical Director stated he had been told by facility staff that the new PCP would sign the orders at discharge and was unaware of the home care agency’s requests for his signature until early March; he indicated he would have signed the orders if he had known the PCP would not sign and that the resident was not receiving services. The record review confirmed there was no evidence the facility communicated to the home care agency that the PCP was new and would not sign orders before seeing the resident, and no timely response to the agency’s and family’s calls, leading to the interruption of ordered home health services following discharge.
Failure to Treat Resident with Dignity and Respect During Care
Penalty
Summary
A resident with diagnoses including anxiety, depression, and heart failure, who was cognitively intact and required substantial assistance with activities of daily living, reported being treated disrespectfully by two nursing assistants during care. The resident stated that the staff were rude and, when requesting their phone, one staff member responded with explicit language indicating disregard for the resident's request. The incident was corroborated by the resident's roommate, who overheard the verbal exchange and confirmed the use of inappropriate language by the staff. Documentation also showed that the resident expressed fear for their safety at the facility, stating they felt threatened by the staff involved. Further review revealed that one of the staff members admitted to telling the resident they did not care about the phone and suggested the resident look for it themselves. The staff member received a verbal notice for violating employee conduct rules, including disrespectful conduct. During interviews, the resident expressed ongoing fear and anxiety related to the night shift staff, specifically those involved in the incident. Facility leadership, including the Director of Social Work and the Administrator, were unable to provide evidence that the staff treated the resident with dignity and respect.
Failure to Implement Surgical Wound Care Orders Upon Admission
Penalty
Summary
A deficiency occurred when a resident admitted with a diagnosis including sepsis due to Serratia did not receive surgical wound care as directed in the hospital's continuity of care document. The discharge instructions specified that the resident's left hip incision site should be cleansed with Vashe cleanser, patted dry, and covered with an antibacterial dressing and protective cover daily and as needed. Although these instructions were provided to the facility upon admission, there was no evidence that a physician's order for the wound treatment was implemented until three days after admission. Staff interviews confirmed that the surgical wound care instructions were present in the admission documentation but were not acted upon until several days later. The Unit Manager acknowledged the delay, and the Nurse Practitioner stated that the treatment order should have been implemented upon admission. The DON was unable to provide evidence that the wound care order was carried out as required during the initial days following the resident's admission.
Failure to Date Thawed Nutritional Supplements and Maintain Clean Ice Machine
Penalty
Summary
Surveyor observation and staff interviews determined that the facility failed to store and distribute food in accordance with professional standards in the main kitchen. Specifically, thirty-four Vital Cuisine Mighty Shakes were found in the walk-in refrigerator without a use-by date to indicate when the product was thawed, despite the manufacturer's label stating the product should be used within 14 days of thawing. The Food Service Director acknowledged that the Mighty Shakes were not dated at the time of observation. Additionally, the ice machine in the main kitchen was observed to have an accumulation of a pink wipeable substance on the ice dispenser shield, which was confirmed by the Regional Food Service Director, who stated the machine had been professionally cleaned three weeks prior.
Non-Functioning Call System in Resident Bathrooms and Bathing Areas
Penalty
Summary
A deficiency was identified due to the lack of a working call system in each resident's bathroom and bathing area. This observation indicates that residents did not have access to a functioning means of summoning assistance while in these locations. The report specifically notes the absence of a working call system, but does not provide additional details about individual residents, their medical history, or their condition at the time of the deficiency.
Failure to Provide Dignified Incontinence Care Prior to Resident Leave
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease and severe cognitive impairment, who was dependent on staff for toileting and hygiene due to bowel incontinence, was not provided with appropriate incontinence care prior to leaving the facility for a hospital visit. Surveyor observation revealed that a Certified Medication Technician escorted the resident to the lobby and out to a family member while the resident had a strong odor of fecal incontinence. The resident was visibly soiled, with loose stool running down their pants and into their shoes, which was immediately noticed by the family member and the surveyor. The family member, who had called ahead to arrange for the resident to be ready for a hospital visit with a dying spouse, was visibly upset and questioned why the resident was handed over in such a condition. The staff member who escorted the resident did not acknowledge the incontinence, and the Director of Nursing Services confirmed that the expectation was for residents to be clean and have incontinence care provided before leaving the facility. No evidence was provided to show that the resident was treated with respect and dignity in this instance.
Failure to Follow Professional Standards in Physician Orders and Dietary Restrictions
Penalty
Summary
The facility failed to ensure that residents received care in accordance with professional standards of practice in two separate cases. In the first case, a resident with a diagnosis including fibromyalgia was readmitted and attended a urology consult, which recommended an increase in fluid intake. However, there was no evidence of a physician's order to encourage fluids upon the resident's return. The unit manager acknowledged that such an order should have been in place, and it was later revealed that an order to encourage extra fluids was entered by a nurse without consulting the resident's provider. The nurse practitioner confirmed she did not approve the order, and the nurse admitted to entering it without provider authorization. In the second case, a resident with dysphagia had a physician's order specifying that no paper products should be present on the meal tray. Despite this, the resident was observed with a tray ticket, tray mat, and napkin during a meal. Staff interviews confirmed awareness of the dietary restriction, but the items were still provided to the resident. The director of nursing stated that nursing staff are expected to review meal tickets and ensure compliance with such orders, but this was not done in this instance.
Failure to Implement and Document Daily Weights for Resident with CHF
Penalty
Summary
A resident with a diagnosis of congestive heart failure (CHF) was admitted to the facility and had a care plan in place that included monitoring for signs and symptoms of CHF, such as weight gain. Hospital discharge documents included a physician's order for daily weights, with instructions to notify the provider if the resident's weight increased by more than 3 pounds in a day or 5 pounds in a week. However, there was no evidence that this order was accepted or declined by a facility provider upon admission. Further review showed that a physician's order for daily weights was not implemented until 17 days after admission. Documentation revealed that daily weights were not recorded on 11 out of 24 days during the review period. Interviews with the nurse practitioner and the Director of Nursing Services confirmed that there was no evidence the resident's weight was monitored daily as required by the care plan and physician's order.
Medication Error Rate Exceeds 5% Due to Multiple Administration Errors
Penalty
Summary
The facility failed to ensure that residents' medication regimens were free from medication error rates of 5% or greater, as evidenced by three medication errors out of 28 observed opportunities, resulting in a 10.71% error rate. In one instance, a resident with an order for Keppra oral tablets to treat epilepsy was instead prepared to receive an unmeasured dose of liquid Keppra by an LPN, who acknowledged both the inaccurate measurement and the incorrect medication form. In another case, a resident with an order for GlycoLax powder to be mixed with 6 ounces of fluid was prepared to receive the medication mixed in only approximately 4 ounces of water, with the LPN failing to accurately measure the prescribed amount of fluid despite being questioned by the surveyor. Additionally, the same resident had an order for Fluticasone nasal spray, to be administered as one spray in each nostril twice daily. However, the LPN handed the medication to the resident without confirming self-administration authorization, and the resident self-administered two sprays in each nostril instead of one. There was no documentation of an order permitting self-administration, and the LPN acknowledged both the deviation from the prescribed dose and the lack of a self-administration order. The Director of Nursing Services confirmed that medications should be administered according to physician orders and that self-administration requires proper assessment and authorization.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with dementia and severely impaired cognition, who was independently ambulatory, entered the room of another resident with a history of traumatic brain injury and mood disorder, also with severely impaired cognition. The resident whose room was entered had a documented history of becoming verbally upset and agitated when others entered his personal space, with two prior incidents of yelling and cursing at other residents who entered his room. Despite these prior incidents, no new interventions were implemented to prevent further altercations. On the date of the incident, staff overheard yelling and found the first resident on the floor in the second resident's room. While staff assisted the resident off the floor, the resident whose room was entered struck the other in the face, resulting in a bloody nose and facial bruising. The facility's failure to implement interventions after the initial two incidents allowed for a third altercation, which resulted in physical harm to the resident.
Failure to Provide and Document Safe Discharge Planning
Penalty
Summary
The facility failed to provide and document adequate preparation and orientation for a resident prior to discharge, as required by policy. A resident with diagnoses including aftercare following hip replacement, PTSD, and osteoarthritis, who was cognitively intact, informed the nurse practitioner of their intent to leave against medical advice. The NP documented that the resident was safe and medically cleared for discharge, but there was no evidence of a physician's order for discharge, an interdisciplinary discharge plan, a notice of discharge, a discharge summary, or a medication reconciliation in the resident's record. Staff interviews confirmed that the unit nurse did not complete any discharge planning, discharge summary, or medication reconciliation for the resident. The Assistant Director of Nursing Services also could not provide evidence that the resident received an appropriate discharge. The resident reported leaving the facility with a friend and not receiving any paperwork, medications, or referrals to home care services. These actions and omissions resulted in a lack of documented and coordinated discharge planning for the resident.
Failure to Supervise and Complete Discharge Procedures for Resident Who Left Facility
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and appropriate discharge procedures, resulting in the resident leaving the facility without staff knowledge or proper documentation. The resident, admitted with diagnoses including aftercare following a hip replacement, post-traumatic stress disorder, and osteoarthritis, had intact cognition as indicated by a recent mental status evaluation. On the day of the incident, the resident expressed a desire to leave and was medically cleared for discharge by a nurse practitioner, but no formal discharge order, signed AMA paperwork, or discharge summary was completed. Throughout the day, multiple staff members noted the resident's intention to leave and observed behaviors such as packing belongings and arranging a ride with a friend. Despite these observations, staff did not ensure the resident remained in the facility until proper discharge procedures were completed. The resident was not present for scheduled rounds or meetings, and staff assumed at various points that the resident was either at an appointment or would wait for discharge planning. It was not until a late afternoon meeting that staff realized the resident was missing, prompting an Elopement Code and a search of the facility. After failing to locate the resident, staff assumed the resident had left against medical advice but did not notify law enforcement as required by facility policy. There was no evidence of a completed discharge process, medication reconciliation, or referral to home care services. Interviews with staff and the resident confirmed that the resident left the facility with a friend, did not receive necessary paperwork or medications, and that the facility did not follow its own elopement and discharge protocols.
Failure to Ensure Safe and Documented Resident Discharge
Penalty
Summary
The facility failed to administer its operations in a manner that ensured effective and efficient use of resources to maintain the highest practicable well-being of a resident who left the facility. According to the report, a resident left the facility at an unknown time, and staff did not realize the resident was missing until several hours later. An Elopement Code was called when staff noticed the absence, but it was cleared based on the assumption that the resident had been discharged, as the resident had expressed a desire to go home and their belongings were missing. However, there was no documentation or evidence to confirm a safe discharge, and the facility was unable to determine the exact time or circumstances of the resident's departure. Interviews with the DON and Administrator revealed that both were uncertain about when the resident left and could not provide evidence of a proper discharge process, including the provision of paperwork, medications, or homecare services. The resident later confirmed that they left with a friend and did not receive any discharge materials or arrangements. The facility's management did not take appropriate action to ensure the resident's safety or to verify the resident's whereabouts in a timely manner.
Inaccurate Medication Administration Documentation for Absent Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that resident records were complete and accurately documented regarding medication administration for a resident who left the facility. The resident, who had diagnoses including aftercare following a hip replacement, post-traumatic stress disorder, and osteoarthritis, was admitted in May 2025 and had intact cognition as evidenced by a Brief Interview for Mental Status score of 14 out of 15. A physician's order was in place for Acetaminophen 325 mg, two tablets three times daily. The Medication Administration Record (MAR) showed that the 2:00 PM dose of Acetaminophen was documented as administered on 5/29/2025 by an LPN. However, the resident reported leaving the facility around 11:00 AM on the same day and did not return. The LPN initially believed the resident was present in the room at 2:00 PM and had eaten lunch, but later acknowledged being unaware that the resident had left earlier and admitted that the documentation of the 2:00 PM medication administration was inaccurate. The Director of Nursing Services confirmed that medications should only be documented as administered if actually given and could not explain the discrepancy in the record.
Deficiencies in Medication Management and Wound Care
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for several residents. Resident ID #35, who was readmitted with a baclofen pump, did not have proper wound care orders transcribed or executed for 22 days following a surgical follow-up. The resident's surgical site was not monitored as ordered, leading to a possible infection. Additionally, there was no care plan or physician's order in place for the management of the baclofen pump, including monitoring for alarms or symptoms of withdrawal, which staff were unaware of. For Resident ID #71, the facility did not adhere to medication administration parameters. The resident, who had a diagnosis of takotsubo cardiomyopathy, was prescribed Metoprolol Succinate with a specific instruction to hold the medication if the apical pulse was below 60. However, there was no documentation of the apical pulse being checked before administering the medication. Similarly, Resident ID #137, who was prescribed Humalog insulin with parameters to hold if blood glucose was below 100 mg/dL, received the medication despite blood glucose readings below the threshold on two occasions. Resident ID #76 missed two doses of the antibiotic Bactrim DS, prescribed for a urinary tract infection, and there was no evidence that the provider was informed of these missed doses. The facility's failure to report the missed doses to the NP was acknowledged by the Interim DNS. These deficiencies highlight a lack of adherence to medication administration protocols and inadequate communication regarding resident care needs.
Failure to Schedule Consultations and Document Wound Care
Penalty
Summary
The facility failed to ensure that residents received necessary follow-up care and consultations as ordered by physicians. Resident ID #117, who was admitted with dementia, had a mammogram consultation ordered due to redness and discharge from the left nipple. However, there was no evidence that the mammogram was scheduled until it was brought to the facility's attention by the surveyor. Similarly, Resident ID #111, with chronic kidney disease and dementia, had a hematology consult ordered due to elevated white blood cell count, but it was not scheduled until after the surveyor's intervention. Resident ID #19, diagnosed with a duodenal ulcer and gastro-esophageal reflux disease, had a GI consult and endoscopy ordered as early as March 2024. Despite the order being marked as completed in the Medication Administration Record, there was no evidence that the consult or procedure was scheduled. Additionally, Resident ID #71, with Multiple Sclerosis, was recommended for an ENT follow-up after ear wax removal, but the appointment was not scheduled as ordered. Furthermore, the facility failed to document wound care adequately for Resident ID #135, who had multiple wounds and was on enhanced barrier precautions. The records lacked detailed documentation of wound size, edges, and surrounding tissue condition, contrary to the facility's policy. Despite ongoing treatments and follow-up by the wound team, the facility's staff could not provide evidence of proper wound documentation, leading to a deficiency in care.
Deficiencies in Bed Rail Assessments and Documentation
Penalty
Summary
The facility failed to complete comprehensive assessments and entrapment evaluations for residents using bed rails across all three floors, affecting numerous residents. The facility's policy requires that bed rails should only be used after evaluating alternatives and obtaining informed consent, yet these steps were not documented for any of the residents observed. The surveyor's observations revealed that residents had bilateral bed rails installed without evidence of completed assessments, informed consent, or documentation of attempted alternatives. Specific deficiencies were noted in the records of multiple residents, including the absence of documentation regarding the benefits and risks of bed rail use, alternatives attempted, and informed consent. For instance, Resident ID #4, admitted with dementia and violent behaviors, had bilateral bed rails without documented evidence of the required components for bed rail use. Similarly, Resident ID #20, with difficulty walking and lack of coordination, also had bilateral bed rails without documentation of potential risks, alternatives attempted, or informed consent. Interviews with facility staff, including the LPN, Regional Maintenance Director, and Assistant Administrator, confirmed that the necessary evaluations and consents were not completed. The facility's failure to identify the manufacturer, model, and serial numbers of the beds and bed rails further compounded the issue, as it prevented the determination of compatibility to mitigate entrapment risks. The Administrator and Interim DNS acknowledged these deficiencies, indicating a systemic failure to adhere to federal regulations and facility policies regarding bed rail use.
Failure to Adhere to Infection Control Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to contact precautions for residents with known or suspected infections. Resident ID #148, who was on contact precautions for ESBL, was observed multiple times with staff entering the room without wearing the required gown and gloves, despite clear signage indicating the need for such precautions. Staff members, including a podiatrist, a certified medication technician, and a nursing assistant, acknowledged their failure to comply with the posted precautions during interviews with surveyors. Similarly, Resident ID #120, who tested positive for RSV and was on contact precautions, was observed sharing a room with another resident. Staff entered the room without wearing the necessary personal protective equipment, such as gowns and gloves, as required by the facility's policy and the posted signage. The infection preventionist and the interim director of nursing services both confirmed that they expected staff to adhere to the posted precautions. Additionally, Resident ID #19, with a known history of ESBL, was not placed on contact precautions or enhanced barrier precautions, contrary to CDC guidelines and the facility's policy. There was no evidence of negative testing to confirm the resident was no longer colonized with ESBL, and no signage or PPE was available to indicate the need for precautions. The infection preventionist admitted that the facility did not follow CDC guidance for managing MDROs after treatment completion.
Failure to Ensure Effective Communication for Hearing-Impaired Resident
Penalty
Summary
The facility failed to ensure a resident's right to communication and access to services, which compromised the resident's dignified existence. Resident ID #333, who was admitted with a diagnosis of hearing loss and relies on lip reading for communication, was unable to communicate effectively due to a mask mandate on the floor where they reside. The resident expressed difficulty understanding the surveyor because of the mask, and the care plan did not initially identify the resident's hearing impairment or their reliance on lip reading. The facility's Assistant Administrator incorrectly stated that an ASL interpreter was used for communication, despite the resident not knowing ASL. The Speech Therapist confirmed the resident's reliance on lip reading and noted the communication challenges faced during therapy. A communication board was provided only after the surveyor identified the issue. The care plan was updated to address the hearing impairment and included the use of a dry erase board for communication, but this was only after the deficiency was noted by the surveyor.
Failure to Include PASARR Recommendations in Baseline Care Plan
Penalty
Summary
The facility failed to ensure that the baseline care plan for a resident included the Preadmission Screening and Resident Review (PASARR) recommendations. The resident, who was admitted with a diagnosis including hearing loss, relies on lip reading for communication. However, the baseline care plan did not identify this communication need as per the PASARR recommendations. This oversight was discovered during a surveyor interview when the resident expressed difficulty in understanding the surveyor due to mask-wearing, which was required on the floor due to a respiratory illness outbreak. The deficiency was further highlighted during an interview with the Speech Therapist, who confirmed the resident's communication challenges and noted that a communication board was only provided after the issue was raised by the surveyor. The Interim Director of Nursing Services acknowledged that the resident's need for alternative communication should have been included in the baseline care plan. The care plan was subsequently updated to address the resident's hearing impairment and communication needs, but this was only after the deficiency was identified by the surveyor.
Failure to Administer Dialysis Medication
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received appropriate medication management, specifically the administration of Velphoro, a phosphate binder necessary for controlling serum phosphorus levels in patients with chronic kidney disease on dialysis. The resident, who was readmitted with end-stage renal disease and dependent on renal dialysis, was prescribed Velphoro 500 mg twice daily. However, the Medication Administration Records for January and February 2025 showed multiple instances where the medication was not administered as ordered. The facility did not notify the physician or the dialysis center about the missed doses until February 4, 2025, despite the medication being unavailable for several days. Interviews with the dietician from the dialysis center and the facility's staff revealed a lack of communication regarding the missed doses. The dietician confirmed that a 90-day supply of Velphoro had been delivered to the facility, and the dialysis center could have provided the medication if informed. The Unit Manager and Nurse Practitioner acknowledged the communication failure, and the Interim Director of Nursing Services could not provide evidence of effective communication with the dialysis center or the resident's provider before February 4, 2025.
Failure to Administer Prescribed Medication for Dialysis Patient
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with end-stage renal disease who was dependent on dialysis. The resident was readmitted to the facility with a prescription for Velphoro, a phosphate binder necessary for controlling phosphorus levels in the blood. Despite a physician's order for the medication to be administered twice daily, the Medication Administration Records indicated multiple instances where the medication was not administered over a period of several days. The deficiency was further highlighted during interviews with facility staff and the dietician from the dialysis center. It was revealed that the facility had received a 90-day supply of Velphoro, but the medication was not administered to the resident. The facility failed to communicate effectively with the pharmacy or the dialysis center to resolve the issue, as evidenced by the lack of documentation of any communication until several days after the medication was supposed to have been delivered.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide a scoop plate for a resident who requires adaptive eating equipment. The resident, who has diagnoses including dementia, muscle weakness, and legal blindness, was observed during a lunch meal without the necessary scoop plate. This resulted in the resident spilling food multiple times while attempting to eat. The care plan and physician's diet order both indicated the need for a scoop plate with all meals, highlighting a failure to adhere to the prescribed dietary interventions. During the survey, a nursing assistant was unaware of the resident's requirement for a scoop plate, despite the diet slip indicating its necessity. The Interim Director of Nursing Services acknowledged the expectation that the resident should have been provided with a scoop plate as ordered. This oversight in providing the appropriate adaptive equipment contributed to the resident's difficulty in eating independently and effectively.
Medication Error Leads to Unnecessary Drug Administration
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medications, as evidenced by a medication error involving two residents with cancer diagnoses. A Registered Nurse mistakenly transcribed a cancer medication, Abiraterone Acetate, intended for a resident with prostate cancer into the medical record of another resident with liver cancer. This error led to the incorrect administration of the medication to the wrong resident for 13 days. The medication bottle was labeled with the correct resident's name, but the error was not caught by the staff administering the medication. The facility's policy requires verification of the resident's identity and medication details before administration, which was not followed by the staff involved. Multiple staff members, including LPNs and a Medication Technician, administered the medication without verifying the resident's name on the prescription bottle. Additionally, two Nurse Practitioners and a Consultant Pharmacist failed to identify the error during medication reconciliation and monthly medication regimen reviews, respectively. The medication, Abiraterone Acetate, is specifically prescribed for prostate cancer, a condition the resident who received it did not have. The failure to transcribe the medication correctly and the subsequent administration of the drug without proper verification placed the resident at risk for serious harm. The facility's oversight in medication management and adherence to policies resulted in the resident receiving unnecessary medication, highlighting significant lapses in the medication administration process and oversight by healthcare professionals within the facility.
Pharmacy Consultant Fails to Identify Medication Irregularities
Penalty
Summary
The facility failed to ensure that medication irregularities were identified by the pharmacist during the monthly drug regimen review for two residents. Resident ID #1, who had a diagnosis of liver cancer but not prostate cancer, was incorrectly administered Abiraterone Acetate, a medication intended for prostate cancer, for 13 days. This error occurred because the medication was transcribed incorrectly into the resident's medical record. The pharmacy consultant completed the medication regimen review for this resident but failed to identify the irregularity, as she did not verify the resident's diagnosis of prostate cancer. Resident ID #3, who was readmitted with a diagnosis of Clostridium difficile, was prescribed Fidaxomicin for 5 days. However, the medication was transcribed to be administered for only 4 days, resulting in the resident not receiving the full course of the medication. The pharmacy consultant also failed to identify this transcription error during the medication regimen review. Both the Registered Nurse and the facility's administration acknowledged the failure of the pharmacy consultant to identify these irregularities during the reviews.
Failure in Medication Administration Audits
Penalty
Summary
The facility failed to implement and maintain an effective Quality Assurance and Performance Improvement (QAPI) program, specifically in the area of medication administration. The QAPI plan included a focus on ensuring residents are free from unnecessary medications, with interventions such as auditing all new medications routinely. However, the facility did not provide evidence that these audits were conducted as planned. This failure led to medication errors, including a transcription error where a medication intended for one resident was mistakenly administered to another resident for 13 days. Additionally, another resident's medication was transcribed incorrectly, resulting in the medication being administered for only 4 days instead of the prescribed 5 days. The report highlights specific incidents involving residents with serious medical conditions. One resident with liver cancer received a prostate cancer medication due to a transcription error, while another resident with a clostridium difficile infection did not receive the full course of antibiotics as prescribed. Interviews with staff and administrators revealed an inability to provide evidence of daily medication order audits, as required by the QAPI plan. These deficiencies were identified during a survey, and the facility's failure to adhere to its QAPI plan contributed to the medication errors.
Medication Error in Antibiotic Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. The resident, who was readmitted with a diagnosis of Clostridium difficile (C. diff), was prescribed Fidaxomicin, an antibiotic, to be administered twice daily for 5 days. However, the Medication Administration Record (MAR) indicated that the medication was transcribed for only 4 days, resulting in a total of 8 doses instead of the prescribed 10 doses. Additionally, the resident did not receive both doses on the first day of administration, and there was no evidence that the provider was informed of these missed doses. Interviews with staff revealed that the error in transcription was acknowledged, and the Nurse Practitioner was unaware of the incomplete course of antibiotics. Despite the resident's ongoing symptoms of loose stools, the Nurse Practitioner decided not to extend the antibiotic treatment. The Chief Nursing Officer confirmed that the resident reported continued loose stools, and the facility's administration acknowledged the failure to administer the full course of the antibiotic as ordered.
Medication Transcription Errors Lead to Incorrect Administration
Penalty
Summary
The facility failed to ensure accurate documentation and transcription of medication orders, resulting in medication errors for two residents. For one resident with liver cancer, a medication intended for another resident with prostate cancer was mistakenly transcribed and administered. This error occurred when a Nurse Practitioner approved a medication order for a resident with prostate cancer, but the order was incorrectly entered into the medical record of a resident with liver cancer. As a result, the resident with liver cancer received a hepatotoxic medication, Abiraterone Acetate, for 13 days, which was not intended for them. In another case, a resident readmitted with a diagnosis of Clostridium difficile infection was prescribed Fidaxomicin for five days. However, the medication was incorrectly transcribed to be administered for only four days, and the resident missed two doses on the first day. This transcription error was acknowledged by the nursing staff and resulted in the resident not receiving the full course of the prescribed antibiotic treatment.
Delayed Call Light Response Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure resident safety, as evidenced by the delayed response to call lights. A complaint was submitted to the Rhode Island Department of Health alleging that a resident did not receive care for 24 hours. During a survey, a resident reported that staff often took 30 minutes to 1 hour to respond to call lights. On one occasion, a surveyor observed that a call light was activated at 11:28 AM and was not answered until 12:04 PM, a delay of 36 minutes. A Licensed Practical Nurse acknowledged the delay and stated that call lights should be answered within 15 minutes. The facility administrator was unable to provide evidence that call lights were answered in a timely manner.
Failure to Provide Adequate Care for Diabetic Ulcers
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident with diabetic ulcers. The resident, who had a history of diabetes mellitus, atopic dermatitis, peripheral vascular disease, and a right foot transmetatarsal amputation, was admitted to the facility with a care plan that required daily foot care and skin inspections. However, there was no evidence that these interventions were consistently performed, as the resident developed infected foot ulcers and cellulitis, which were not identified until a podiatrist appointment led to an emergency hospital transfer. The resident's condition was further compromised by the facility's failure to administer prescribed antibiotics following a hospital discharge. The resident was supposed to receive Augmentin and Doxycycline, but these medications were not transcribed into the resident's record or administered until several days after the resident's return to the facility. This delay in treatment coincided with an increase in the resident's white blood cell count, indicating a potential worsening of the infection. Additionally, the facility did not schedule a timely follow-up appointment with a vascular surgeon, as recommended upon the resident's discharge from the hospital. The resident's condition continued to deteriorate, with multiple diabetic ulcers and pressure ulcers developing, some of which were unstageable due to eschar. The facility's lack of timely and appropriate care placed the resident at risk for serious harm, including potential amputation, as noted by the resident's podiatrist and other healthcare professionals involved in the resident's care.
Failure to Honor Resident's Right to Refuse Treatment
Penalty
Summary
The facility failed to honor a resident's right to refuse treatment, as evidenced by the administration of Trazodone without the resident's consent. The resident, who was cognitively intact with a perfect score on a mental status assessment, was admitted with conditions including cervical disc degeneration, morbid obesity, and hypertensive kidney disease. Despite the resident's explicit refusal of Trazodone, a medication prescribed for anger and irritability, it was administered routinely for three days. The resident only became aware of this when they noticed an unfamiliar pill and inquired about it, realizing it was the cause of their lethargy and inability to enjoy outdoor activities. The issue arose when a Nurse Practitioner (NP) prescribed Trazodone as needed after the resident exhibited anger due to receiving the wrong meal. However, the medication was administered on a scheduled basis, contrary to the NP's order. The NP acknowledged that she did not return to discuss the medication further after the resident's initial refusal. The Director of Nursing Services confirmed that the resident should have been informed and consented to the treatment, highlighting a failure in communication and adherence to the resident's rights.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to a resident at risk for pressure ulcers, leading to the development of pressure ulcers on both heels. The resident, who was admitted with conditions including diabetes mellitus, atopic dermatitis, and peripheral vascular disease, was initially assessed as being at risk for pressure ulcers but had no ulcers at the time of admission. Despite a care plan intervention for daily foot care and prompt reporting of any skin issues, a stage 1 pressure ulcer was identified on the resident's right heel on 8/7/2024, but no immediate intervention was documented. Further assessments revealed the progression of the right heel ulcer to an unstageable status with 100% slough and the development of a new unstageable ulcer on the left heel with 100% eschar. Wound care orders were delayed, not being implemented until two days after the assessment. Observations by surveyors on multiple occasions found the resident's heels were not offloaded as required, and there was no documentation of the resident refusing the offloading booties. The resident expressed willingness to have their feet offloaded to aid healing, yet the facility failed to ensure this was consistently done. Interviews with staff, including a registered nurse and the Director of Nursing Services, confirmed the lack of adherence to the care plan and wound care orders. The nurse practitioner was observed handling the resident's wounds inappropriately by picking and peeling skin. The Director of Nursing Services could not provide evidence that the resident received the necessary treatment and services to promote healing and prevent new pressure ulcers, indicating a significant lapse in care and oversight by the facility.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who required such services following a left knee arthroplasty. The resident was admitted with a care plan that included administering pain medication as ordered by the physician. However, despite a physician's order for oxycodone to be administered every six hours as needed, the medication was not available to the resident due to a delay in delivery from the pharmacy. This resulted in the resident experiencing significant pain, which was reported to the nursing staff. The resident expressed experiencing a pain level of 7 out of 10 and reported increased pain during movement and therapy. Despite the availability of a pyxis system to access medications not yet delivered by the pharmacy, the staff did not utilize it to obtain the necessary pain medication. The resident's pain was only addressed after the nurse contacted the physician to resend the prescription, and the medication was finally administered the day after the resident reported the issue. The Director of Nursing Services acknowledged that the resident should have been medicated for pain as ordered and expected the staff to use the pyxis system in such situations.
Failure to Implement GDR and Mismanagement of Psychotropic Medication
Penalty
Summary
The facility failed to ensure a resident's drug regimen was free from unnecessary psychotropic drugs and did not implement a gradual dose reduction (GDR) as recommended. For one resident, Trazodone was prescribed as needed for anger and irritability but was administered as a scheduled medication. The resident's cognition was intact, and the medication was given routinely over several days, contrary to the as-needed order. The nurse practitioner who prescribed the medication confirmed it was intended for as-needed use, and the Director of Nursing Services acknowledged the order should have been clarified. In another case, a resident with unspecified mood affective disorder and obsessive-compulsive disorder was prescribed Risperidone. A psychiatric evaluation recommended a GDR, but the facility continued administering the original dose for 25 days without implementing the reduction. The Director of Nursing Services could not provide evidence that the recommendation was addressed, and the resident's physician was unaware of the recommendation. The physician stated he would have approved the GDR had he been informed.
Deficiencies in Continence and Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident who was continent of bladder and bowel upon admission. The resident, who had undergone left knee arthroplasty, required assistance with toileting due to mobility issues. However, during a surveyor observation, it was noted that there was no commode or bedpan available in the resident's room, which was necessary for maintaining continence. The resident expressed that they were not incontinent before admission and required assistance and equipment for toileting. Despite being aware of the resident's continence status, the facility staff did not provide the necessary equipment until after the surveyor's observation. Additionally, the facility failed to obtain a urine analysis (UA) for the same resident, who reported new symptoms of burning during urination after leaving the hospital. Although a physician's order was placed to obtain a UA and culture, the facility's records did not show evidence that the UA was obtained until two days later, after the surveyor's inquiry. The resident expressed concern about the delay in obtaining the urine sample, which was later confirmed to be positive for a urinary tract infection (UTI). The facility also failed to provide appropriate care for two residents with suprapubic catheters. One resident missed a scheduled urology appointment due to a lack of communication and scheduling oversight by the facility staff. Another resident did not have their catheter changed as per the urologist's order, which was not transcribed into the facility's records. This oversight was only discovered after the resident pulled out the catheter, necessitating a hospital visit. The facility's Director of Nursing Services was unable to provide evidence that the catheter was changed according to the prescribed schedule.
Failure to Obtain Timely Dental Services for Resident
Penalty
Summary
The facility failed to assist a resident in obtaining necessary dental services, specifically an oral surgeon consult for tooth extractions and denture fabrication. The resident, who was admitted in March 2021 with diagnoses including protein-calorie malnutrition and anxiety disorder, had a care plan dated April 2023 indicating oral health problems due to broken teeth and a need for dental care coordination. Despite multiple recommendations from an inpatient dental service provider between September 2023 and June 2024 for an oral surgeon evaluation, the facility did not obtain or attempt to obtain the necessary consult. Interviews with the resident and staff revealed that the resident had been requesting dentures for some time, and staff acknowledged the lack of an oral surgeon consult. The Director of Nursing Services was initially unsure if a consult had been obtained and later confirmed that an appointment was scheduled only after the surveyor's inquiry. The facility's failure to schedule the consult within 30 days of the initial recommendation was acknowledged by the DNS, who could not provide evidence of any prior scheduling efforts before the surveyor's intervention.
Failure to Follow Physician's Orders and Implement Gradual Dose Reduction
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by not following physician's orders for several residents. Resident ID #10, who was readmitted with a diagnosis of diabetes mellitus, had an elevated blood sugar level of 511 mg/dL. A nurse practitioner ordered 14 units of Lispro insulin and a reassessment of blood sugar in one hour, but the order was not documented in the medication administration record, nor was the blood sugar rechecked. Additionally, the resident's HBA1C was not checked as ordered every three months. Resident ID #157, admitted with a diagnosis of cerebral infarction, had a new order for a fecal occult blood test and urinalysis after blood was observed in the stool. However, there was no evidence that these tests were obtained as ordered. Similarly, Resident ID #539, who was admitted with chronic kidney disease, complained of symptoms indicative of a urinary tract infection. A physician ordered a urinalysis, but the sample was not obtained until the surveyor brought it to the facility's attention. The facility also failed to implement a gradual dose reduction for Resident ID #45, who was readmitted with mood affective disorder and obsessive-compulsive disorder. A recommendation to discontinue risperidone twice daily and start a new order for a bedtime dose was approved, but the new order was not transcribed, and the resident did not receive the evening dose as planned. These deficiencies highlight a pattern of not adhering to physician's orders, impacting the care and treatment of the residents involved.
Failure to Ensure Nursing Staff Competency in IV Administration
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies to provide safe and effective care for residents requiring intravenous (IV) administration of fluids. Specifically, two Licensed Practical Nurses (LPNs), identified as Staff A and Staff B, did not complete the mandatory IV competency training. Despite this, they administered fluids and medications via a peripherally inserted central catheter (PICC line) to a resident who was admitted with diagnoses including candidiasis and an abscess of the lung. The resident, who was receiving antibiotics through the PICC line every six hours, reported feeling that the nursing staff did not know how to properly care for the IV. The resident was subsequently sent to the hospital due to an occluded PICC line, indicating a potential lapse in proper IV care and maintenance by the nursing staff involved. During the survey, the Director of Nursing Services confirmed that all nurses are supposed to receive competency education regarding IV fluid administration and IV care. However, she was unable to provide evidence that the required IV competency training had been completed for Staff A and Staff B. This lack of documentation and training directly contributed to the deficiency observed, as the involved staff were administering IV treatments without verified competencies, potentially compromising resident safety and well-being.
Failure to Implement Infection Control Measures for MRSA
Penalty
Summary
The facility failed to maintain an infection prevention and control program to prevent the transmission of communicable diseases and infections for a resident diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA). The resident was readmitted to the facility with a positive MRSA test result from the hospital, which indicated the need for contact precautions. However, upon observation, the resident was not placed on contact precautions, and there was no evidence of appropriate signage or personal protective equipment (PPE) outside the resident's room. Interviews with the Assistant Director of Nursing Services and the Infection Preventionist revealed that they were unaware of the resident's MRSA status, and the necessary precautions were not implemented as per the facility's policy. Further observations revealed that even after the surveyor brought the issue to the facility's attention and a physician's order for contact precautions was put in place, staff failed to comply with the required infection control measures. A registered nurse entered the resident's room without donning PPE, indicating a lack of awareness and adherence to the contact precautions. The Director of Nursing Services acknowledged the oversight and confirmed that the staff should have followed the infection control protocols to prevent the spread of MRSA.
Inadequate Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and services for three residents with indwelling catheters. Resident ID #86 experienced multiple incidents of urinary retention and hematuria due to improper catheter management, including a kinked catheter tubing and missed opportunities to measure and report urinary output. Despite a physician's order to monitor urine output every shift, there were 22 missed opportunities in February 2024, and no evidence that the provider was notified of no urinary output on specific dates in February and March 2024. The resident also had a significant incident where 1700 ml of urine was drained after being sent to the emergency room for abdominal pain and distention, indicating severe urinary retention issues that were not adequately monitored or managed by the facility staff. Resident ID #6, who had a supra pubic catheter, also experienced inadequate monitoring and documentation of urinary output. Out of 36 opportunities to document catheter patency in March 2024, 7 were missed, and there was no evidence that the provider was notified of no urinary output on multiple shifts in early March 2024. Similarly, Resident ID #79, with a foley catheter for bladder-neck obstruction, had no documented evidence of urinary output monitoring for February and March 2024. The Director of Nursing Services acknowledged the lack of documentation and monitoring, indicating a systemic issue in the facility's catheter care practices.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment in 17 of 32 resident rooms observed. Surveyor observations from 3/10/2024 through 3/14/2024 revealed multiple deficiencies, including gouges or missing and chipped paint in rooms 218, 219, 225, 227, 319, 322, 342, 432, 452, 445, and 447. Additionally, ceiling tiles with water stains were noted in rooms 322, 323, 333, and 445, and a ceiling tile with black wooly growth was found in another room. Other issues included a privacy curtain with multiple unidentifiable stains, an electrical outlet with a missing plate cover, a metal mirror frame with missing paint, a sink faucet with black tape, and a portion of the floor with black marring in various rooms. The Maintenance Director acknowledged all findings and agreed they were in need of repair or cleaning.
Failure to Provide Timely and Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident at risk for pressure ulcers received necessary treatment and services consistent with professional standards of practice. Upon admission, the resident had three pressure injuries documented in the hospital continuity of care (COC) documents: a stage 2 ulcer on the left ear, a stage 3 ulcer on the right buttocks, and a deep tissue injury (DTI) on the right heel. However, the facility's initial skin check only identified two of these injuries and failed to include comprehensive assessments such as wound bed description, exudate, wound edges, surrounding tissue, pain, and wound size/measurements as required by the State Operation Manual Appendix PP. The facility did not implement treatments for the identified pressure ulcers in a timely manner. The treatment for the left ear was documented as needed but was not completed, and there was no evidence that the wound healed. Treatments for the right buttocks were inconsistently documented and not initiated until five days after admission. The DTI on the right heel was not treated until four days after admission. The contracted wound care specialist did not measure the sacral wound and the right heel DTI until six days after admission, and the left ear wound was not assessed at all. Interviews with the Unit Nurse Manager, Infection Preventionist, and Director of Nursing Services confirmed the lack of timely and appropriate wound assessments and treatments. The facility failed to provide evidence that the resident received the necessary treatment and services to promote healing and prevent infection, as required by professional standards of practice. This deficiency highlights significant lapses in the facility's pressure ulcer care protocols and documentation practices.
Failure to Supervise Resident Smoking
Penalty
Summary
The facility failed to ensure that Resident ID #77 received adequate supervision and monitoring to prevent accidents related to smoking. The resident, who has multiple sclerosis and depression, was readmitted to the facility in May 2022. Despite the facility's policy that all smoking materials should be stored at the nurses' station and that residents should only smoke in designated areas under supervision, the resident was found to have a history of non-compliance with the smoking policy. Progress notes indicated multiple incidents where the resident was found with marijuana and smoking materials in their room, including a marijuana vape pen and a lighter. The resident admitted to smoking marijuana in bed and keeping a vape pen in their bureau during a surveyor interview on March 14, 2024. Interviews with staff members, including a Nursing Assistant and the Social Worker, confirmed that the resident had previous incidents involving smoking marijuana in their room. The Director of Nursing Services acknowledged that smoking materials should not be in a resident's room and that marijuana use is not permitted on the premises. However, the facility was unable to provide evidence that adequate supervision and monitoring were in place to prevent these incidents. The deficiency was identified based on the facility's failure to enforce its smoking policy and ensure the safety of the resident.
Failure to Ensure Resident's Drug Regimen is Free from Significant Medication Errors
Penalty
Summary
The facility failed to ensure a resident's drug regimen was free from significant medication errors. A surveyor observed a medication cup containing three pills on a resident's bedside table while the resident was unattended and sleeping. The medications were identified as Levetiracetam 1000 mg, Ibuprofen 800 mg, and Baclofen 10 mg, which were not the scheduled medications for that morning. The medications were supposed to be administered the previous evening, but the staff did not witness the resident taking them and left them on the bedside table. The resident, admitted in October 2022, had diagnoses including valgus deformity, hemiplegia, hemiparesis, and pain. The facility's policy requires staff to remain with residents until all medications are taken, which was not followed. The Director of Nursing Services confirmed that the medications were left unattended and not administered as required. This incident highlights a significant medication error and a failure to adhere to the facility's medication administration policy.
Failure to Store Medications in Locked Compartments
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments for a resident, leading to a deficiency. During a surveyor observation, a medication cup containing three pills was found on the bedside table of a resident who was unattended and sleeping. The medications were identified as Levetiracetam, Ibuprofen, and Baclofen, which were not the scheduled medications for that morning. The facility's policy requires all medications to be stored in locked compartments and for staff to remain with the resident until all medications have been taken. However, this policy was not followed in this instance. Further investigation revealed that a Licensed Practical Nurse (LPN) had given the resident the cup of medications during the evening shift but did not witness the resident take them. The LPN acknowledged leaving the medications on the bedside table. The Director of Nursing Services confirmed that the medications were left unattended and not stored in locked compartments, as required by the facility's policy.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program to prevent the transmission of communicable diseases and infections. Resident ID #409, who was admitted with a history of Methicillin-Resistant Staphylococcus Aureus (MRSA) in the nares and wound, did not have the required Enhanced Barrier Precautions implemented upon admission. The resident's hospital discharge documentation indicated a positive MRSA test, but the facility did not place the resident on contact precautions or cohort them with another resident with the same MDRO. The resident was cohorted with a roommate who did not have an MDRO for approximately 21 days, and staff were unaware of the MRSA infection upon admission despite the information being included in the hospital documentation received by the facility. The Infection Preventionist and Director of Nursing Services acknowledged the oversight and the lack of appropriate precautions for the resident's entire admission period. Additionally, the facility failed to follow proper infection control procedures during wound care for Resident ID #79, who had severe conditions including necrotizing fasciitis, a stage 4 pressure ulcer, and osteomyelitis. During a wound care observation, an LPN was seen using a multi-resident package of gauze to cleanse the resident's wound without performing hand hygiene or changing gloves between uses. After completing the wound care, the LPN returned the used package of gauze to the treatment cart for multi-resident use, which is against infection control protocols. The Director of Nursing Services confirmed that the gauze should have been discarded or designated for single-resident use. These deficiencies highlight significant lapses in the facility's infection prevention and control program, particularly in the areas of implementing contact precautions for residents with MDROs and maintaining proper wound care practices to prevent cross-contamination. The facility's failure to adhere to established protocols put residents at risk of infection and communicable diseases.
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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