Greenville Operations Ri Llc Dba Greenville Skille
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenville, Rhode Island.
- Location
- 735 Putnam Pike, Greenville, Rhode Island 02828
- CMS Provider Number
- 415087
- Inspections on file
- 39
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 16 (1 serious)
Citation history
Health deficiencies cited at Greenville Operations Ri Llc Dba Greenville Skille during CMS and state inspections, most recent first.
Failure to prepare thickened liquids according to orders. Staff prepared drinks for multiple residents with dysphagia using the wrong thickener, unlabeled thickening powder, and unmeasured amounts, despite nectar thick liquid orders. Staff were unaware of the residents' liquid consistency requirements, the unit lacked properly labeled thickener with instructions, and the DON acknowledged staff had not been educated on how to properly thicken liquids.
No Weekend Activity Program: The facility failed to provide an ongoing weekend activity program aligned with residents’ assessed preferences and care plans. Residents reported that no activities were offered on Saturdays or Sundays, and the activity schedule showed no activity staff assigned on weekends. Records for several residents documented the importance of meaningful daily routines and leisure activities, including bingo, card playing, coffee socials, and other preferred activities, while the Administrator acknowledged that residents were not offered structured activities on weekends.
The facility failed to complete all required parts of its facility-wide assessment and did not show evidence of annual review of policies and procedures. Record review did not show that the assessment addressed ethnic, cultural, or religious factors, third-party service agreements, HIT resources, or a plan to maximize direct care staff recruitment and retention. The Administrator was unable to provide evidence that all policies and procedures were reviewed annually.
Staff failed to demonstrate competency with thickened liquids and infection precautions. A resident ordered nectar thick liquids was given honey thick thickener or improperly mixed thickener by NAs and an RN, while the DON/DNS could not show staff education or competency records. Staff also did not understand the difference between contact precautions and EBP, and a resident on contact precautions was observed receiving care without the required gown and gloves; annual training records for some staff were missing.
Failure to Match Meals to Resident Diet Preferences: Multiple residents with intact or moderately impaired cognition reported repeated meal errors and received foods that did not match their diet slips or stated preferences. Observations showed mismatches between what was served and what was ordered for meals and snacks, and the RFSM acknowledged that diet slips should match the food being served and that residents should be notified of changes before meals.
Failure to communicate a diet change resulted in a resident missing meals. A resident with cerebral palsy and dysphagia was changed from tube feeding to a pureed diet with thickened liquids after SLP evaluation and a provider order, but the diet communication form was not sent to the kitchen. Surveyors observed the resident without a lunch tray, and the resident, NA, LPN, FSD, and DON all confirmed the resident did not receive breakfast or lunch because the kitchen was not notified of the new diet order.
A resident with dementia and MS had a physician order for weekly skin assessments and a care plan identifying risk for pressure injury and skin breakdown due to incontinence and decreased mobility. The record did not show several ordered skin assessments were completed, and an RN stated the last assessment had been done weeks earlier; the DON could not provide evidence that the assessments were completed as ordered.
Failure to follow surgeon’s wound vac order: A resident with a surgical back wound was ordered to continue NPWT, and the surgeon later changed the setting to 75 mmHg continuous. Staff did not report the updated order to the physician, and surveyors observed the wound vac still set at 125 mmHg until it was changed after surveyor intervention.
A resident with dementia, MS, and a facility-acquired Stage III pressure ulcer on the left buttock did not have continuous wound treatment in place, with a gap in ordered dressing care and no evidence of daily wound monitoring during that period. The record also lacked required weekly wound measurements and wound descriptions, and the RN and DON acknowledged the missing treatment and documentation.
Two residents were observed receiving 2 L of oxygen via nasal cannula without a physician order. One resident, who had CHF and dementia, was seen on multiple occasions receiving oxygen, and an LPN acknowledged there was no order. Another resident, with respiratory failure and anxiety, was also receiving oxygen without an order, and the room lacked oxygen caution signage; the Unit Manager and DNS acknowledged the missing order.
Inaccurate dialysis fluid restriction monitoring: A resident with ESRD on dialysis had a physician-ordered 1,200 mL/day fluid restriction, but intake was not totaled every 24 hours and the written fluid restriction records did not match the MAR. The MAR showed multiple days when documented intake exceeded the ordered limit, and there was no evidence that a provider was notified. An LPN acknowledged the documentation was inconsistent, and the DON and MD stated intake should be accurately monitored and reported when over the restriction.
Delayed Response to Pharmacy Medication Regimen Review Recommendations: The facility did not address pharmacy recommendations within the required 30-day timeframe for two residents. One resident with PTSD and anxiety had recommendations for dose reduction of trazodone, quetiapine, and sertraline that were not documented as addressed on time, and another resident with Parkinson’s and schizophrenia had a recommendation to update a Lasix order to match how the pharmacy was dispensing it. The DON could not provide evidence that the January pharmacy recommendations were acted on within the facility’s policy timeframe.
A resident receiving warfarin for atrial fibrillation and HF experienced a significant med error when a PT/INR result was not reported to the physician in a timely manner, resulting in a missed warfarin dose. The record also showed a later ordered PT/INR was not documented as obtained as ordered, and the UM acknowledged both the missed dose and the delayed reporting.
Drugs and biologicals were not stored according to accepted professional principles in 1 medication room and 1 medication cart. Surveyors found two opened, undated bottles of lorazepam in the Lilly Unit med room despite manufacturer instructions to discard the bottle 90 days after opening. In the Sun Unit med cart, a Biotene mouthwash bottle lacked resident identifiers and had an uncovered, dirty nozzle with debris and hair present; staff and the DON acknowledged the storage issues.
A resident with dementia and malnutrition was admitted with full upper dentures, but staff were unaware of the need for denture care, and documentation did not show evidence of assistance. The facility's oral health policy also lacked required procedures for lost or damaged dentures and did not specify that residents may not be charged for such loss.
Surveyors found that the main kitchen failed to follow professional food safety standards, with mold present in the walk-in refrigerator, dirty storage racks, and food items that were past discard dates or improperly labeled. Additional issues included leaking juice containers and broken eggs, all of which were acknowledged by the Food Service Director and Administrator as not meeting required standards.
Two residents experienced injuries due to the facility's failure to follow safe transfer protocols and implement fall prevention interventions. One resident with dementia and mobility issues was transferred without a walker or gait belt, resulting in a severe leg wound requiring sutures. Another resident with cognitive impairment and a history of falls suffered a hip fracture after an unwitnessed fall, with no new interventions added to the care plan after a prior fall.
A resident with cerebral palsy and intact cognition, who communicates with some difficulty, was held by staff and administered medications via G-tube after repeatedly refusing them. Staff interviews confirmed that a nursing assistant assisted in restraining or distracting the resident while a nurse administered the medications, contrary to facility policy requiring respect for a resident's right to refuse treatment.
Surveyors found deficiencies in the facility's main kitchen, including unclean walls, a dusty fan, and a grimy floor drain, violating the Rhode Island Food Code. Additionally, a spray cleaning bottle lacked proper labeling, breaching OSHA standards. The Regional Executive Chef acknowledged these issues.
The facility failed to monitor dialysis care and fluid restrictions for two residents. One resident with end-stage renal disease was not assessed for their AVF's bruit and thrill, and their MOLST form was not updated. Another resident with stage 4 chronic kidney disease was not monitored for their fluid restriction, leading to potential fluid overload. Staff interviews confirmed the lack of monitoring and documentation.
A resident with dementia and hypotension was administered Midodrine despite having a systolic blood pressure exceeding the physician-ordered parameters. The facility staff, including a registered nurse and the Director of Nursing, acknowledged the failure to follow the order. The resident's physician was unaware of the deviation from the prescribed parameters.
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of antibiotic time-outs for two residents prescribed antibiotics for infections. Additionally, the facility did not have a system to track antibiotic use, including days of therapy, as recommended by the CDC. This was acknowledged by the facility's DNS and Infection Preventionist during interviews.
Two residents with intact cognition did not receive meals according to their preferences, as indicated on their meal tickets. One resident, who dislikes eggs, was served them instead of pancakes, while another resident received a turkey patty instead of a shredded pork sandwich and coleslaw. The facility staff acknowledged these discrepancies, indicating a failure in adhering to meal ticket instructions.
The facility failed to ensure that residents were free from physical restraints not required to treat medical symptoms. Two residents were restrained without proper assessments, consent, or physician orders. Staff members admitted to restraining residents due to fall risk concerns, and the facility's administration confirmed the use of physical restraints and acknowledged the lack of proper documentation.
The facility failed to investigate and report abuse allegations involving two residents, allowing the alleged perpetrators to continue working and resulting in further abuse. Despite immediate reports to an LPN, no action was taken until seven days later, leading to additional incidents of abuse.
A resident with severe cognitive impairment was physically abused and restrained by staff members in the day room. The abuse was reported by another NA, and video footage confirmed the aggressive actions. The resident was found with multiple bruises, and staff admitted to restraining the resident to prevent falls.
The facility's QAPI committee failed to develop and implement plans to correct deficiencies related to resident abuse and rights. Incidents of abuse were not reported or addressed promptly, and the facility did not develop a comprehensive plan to monitor and evaluate performance indicators, leading to Immediate Jeopardies.
The facility failed to ensure staff competency in restraint use, leading to the inappropriate physical restraint of two residents by a nursing assistant and a certified medication technician. The involved staff had not completed mandatory training on restraint and seclusion.
A pharmacist failed to report irregularities in a drug regimen review for a resident with dementia, anxiety, and depression. The resident had a physician's order for Lorazepam without an end date or documented rationale for extended use. The pharmacist's reports from December to April did not identify this issue, and the pharmacist could not provide evidence that the irregularity was reported to the attending physician, Medical Director, and DNS.
A resident with dementia, anxiety, and depression received Lorazepam without a seizure disorder diagnosis. The medication order lacked an end date, and the drug was administered for scratching, not seizures. The LPN and DON confirmed the medication was given incorrectly.
The facility failed to ensure that 5 out of 7 direct care staff members completed mandatory effective communication training for 2023. During an interview, the Regional Nurse, Administrator, and DON could not provide evidence of completed training for these staff members.
The facility failed to provide mandatory QAPI training to all staff. Record review showed that five staff members, including NAs and a Certified Medication Technician, did not complete the required training for 2023. During an interview, the Regional Nurse, Administrator, and DON could not provide evidence of completed training for these staff members.
The facility failed to provide mandatory compliance and ethics training to five staff members, as required. Record review and an interview with the Regional Nurse confirmed the lack of evidence for completed training for these staff members.
The facility failed to provide mandatory behavioral health training to five staff members, including Nursing Assistants and a Certified Medication Technician, as required for 2023. The Regional Nurse, Administrator, and DON confirmed the lack of evidence for completed training.
The facility failed to treat two residents with respect and dignity. One resident was left exposed and aggressively handled by staff, while another was left unattended in a recliner chair. Both residents have severe cognitive impairments and were not properly monitored, as confirmed by staff interviews and video footage.
Failure to Prepare Thickened Liquids According to Orders
Penalty
Summary
The facility failed to ensure that residents prescribed nectar thick liquids received beverages prepared in the correct form. The report identified three residents with dysphagia and physician orders for nectar thick liquids: one resident with cerebral palsy and a gastrostomy tube, one resident with dementia and dysphagia, and one resident with dementia and cognitive communication deficit. The facility policy stated that residents requiring thickened liquids should receive beverages prepared to the correct consistency using the facility-approved thickening agent according to the manufacturer's instructions. For one resident, staff mixed a packet of honey consistency thickener into milk even though the order was for nectar thick liquids. The staff member stated he was unaware of the resident's liquid consistency order and acknowledged the packet was for honey consistency, not nectar. A nurse confirmed the resident should receive nectar thick liquids and stated honey thick packets were the only packets available on the unit, with thickener sometimes delivered from the kitchen when packets were unavailable. For another resident, staff prepared juice using two heaping spoonfuls of white powder from an unlabeled container, and the staff member stated he did not know the ordered liquid consistency or how much thickener was needed. The dietary aide stated the kitchen sent thickener in an unlabeled plastic container without the manufacturer's label or instructions, and the thickener was observed stored in the kitchen in a container without labeling or instructions. For the third resident, staff again used an unlabeled container of white powder and added heaping spoonfuls to milk and coffee without measuring the amount. Staff acknowledged not knowing the resident's order or how to achieve nectar thick consistency, and the DON stated staff had not been educated on how to properly thicken liquids.
No Weekend Activity Program
Penalty
Summary
The facility failed to provide an ongoing activity program on the weekends to support residents in their choice of activities based on comprehensive assessments, care plans, and preferences. Surveyor observation, clinical record review, and staff and resident interviews showed that no activity staff were scheduled to work on Saturdays and Sundays, and residents in the Resident Council stated that no activities were offered on those days. The facility policy stated that residents have the right to participate or not participate in leisure and recreation of their choosing and should be invited and encouraged to assist in planning recreation programming. Record review for five residents showed that each had documented preferences for meaningful daily routines and leisure activities. Resident #7 had diagnoses including anxiety, a BIMS score of 15, and a care plan noting the importance of engaging in daily routines meaningful to preferences. Resident #42 had diagnoses including anxiety and depression, a BIMS score of 13, and a care plan stating the importance of meaningful daily routines. Resident #49 had diagnoses including anxiety and depression, a BIMS score of 15, and a similar care plan. Resident #70 had diagnoses including depression and anxiety, a BIMS score of 15, and a care plan stating the importance of meaningful daily routines. Resident #71 had diagnoses including adjustment disorder and dementia, a BIMS score of 9, and a care plan noting enjoyment of leisure activities including coffee social, card playing, games of chance, and bingo. The Administrator acknowledged that no activities staff were scheduled and that residents were not offered structured activities on the weekends.
Incomplete Facility Assessment and Missing Annual Policy Review
Penalty
Summary
The facility failed to implement all required components of its facility-wide assessment and failed to annually review its policies and procedures. Review of the Facility Assessment dated 1/5/2026 stated that policies and procedures should be reviewed to ensure they meet current professional standards of practice and regulatory requirements and that gaps or areas requiring updates should be identified based on evaluation findings. Record review did not reveal evidence of annual reviews of the policies and procedures, and it also did not reveal evidence that the facility assessment addressed ethnic, cultural, or religious factors affecting care, contracts or agreements with third parties for services or equipment during normal operations and emergencies, health information technology resources for electronic records and information sharing, or a plan to maximize recruitment and retention of direct care staff. During an interview on 3/5/2026 at 12:02 PM, the Administrator was unable to provide evidence that the facility reviews all of its policies and procedures annually.
Staff Competency Failures for Thickened Liquids and Infection Precautions
Penalty
Summary
The facility failed to ensure nursing staff had the competencies needed to provide care for residents requiring thickened liquids. Resident ID #30 had an order for a regular diet with pureed texture and nectar thick liquids, but a NA mixed a packet of honey consistency thickener into the resident’s milk and stated he was unaware of the resident’s liquid consistency order. An LPN acknowledged that nectar thick liquids were ordered, but also stated that honey thick packets were the only packets available. Resident ID #39 had an order for nectar thick liquids, yet a NA mixed two heaping spoonfuls of white powder from an unlabeled container into juice and stated he did not know the ordered fluid consistency or how much thickener to use. Resident ID #17 also had an order for nectar thick liquids, but a NA mixed white powder into milk and coffee without knowing the resident’s liquid consistency order or how much thickener to add. An RN stated that two to three scoops should be added to each drink for any resident requiring thickened liquids, and the DNS stated she was unaware of how to achieve nectar thick consistency and could not provide evidence of staff education or competencies related to thickening liquids. The facility also failed to ensure staff understood and followed contact precautions and enhanced barrier precautions (EBP). A resident with a contact precaution sign posted outside the room was observed receiving meal assistance and later entering care without staff wearing gown and gloves as required. Staff members stated they were unsure of the difference between contact precautions and EBP, and the Unit Manager incorrectly described universal precautions as the same as EBP. In addition, the facility could not provide evidence that three staff members had received annual training related to EBP and contact precaution practices, and the DNS was unable to provide that documentation when asked.
Failure to Match Meals to Resident Diet Preferences
Penalty
Summary
The facility failed to accommodate residents’ food preferences and diet slips for 4 of 4 residents reviewed who voiced concerns about receiving incorrect meals. Resident #11, admitted with anemia and assessed with a BIMS score of 12, stated that the facility did not follow diet preferences and that the diet slips did not match the food being served. During observation, the resident was served a pork chop, mashed potatoes, and cake, while the diet slip indicated parslied noodles and pudding. Resident #13, who had heart failure and intact cognition, reported that incorrect meals were served all the time despite selecting preferences and reporting discrepancies to dietary staff. Observations showed the resident received mashed potatoes and vanilla cake when the diet slip called for mashed sweet potato and chocolate covered pumpkin cake, and at breakfast received scrambled eggs and toast when the diet slip specified sliced bread, egg whites, and an egg sandwich. Resident #31, who had type 2 diabetes mellitus and intact cognition, also reported repeated meal errors; observations showed chicken, french fries, and cake instead of a baked pork chop, baked sweet potato wedges, and pumpkin pie, and later french toast was served when the diet slip called for regular toast and egg whites. Resident #65, admitted with anemia and intact cognition, stated that meals were incorrect and sometimes not enough nutrition; observation showed vanilla pudding was served when the diet slip specified chocolate pudding. The Regional Food Service Manager acknowledged that the diet slip should match what is being served for all meals and that residents should be notified of changes before meals are served.
Failure to Communicate Diet Change Resulted in Missed Meals
Penalty
Summary
The facility failed to ensure a resident was free from neglect related to meal service after a diet order change. Resident ID #30, who had diagnoses including cerebral palsy and dysphagia, was hospitalized for pneumonia, then readmitted requiring temporary gastrostomy tube feeding while awaiting speech and dietary consultation. The resident was evaluated by the SLP, who recommended mildly thick drinks and pureed foods, and a physician later entered an order for a regular diet with pureed texture and nectar thick liquids. On the day of the deficiency, surveyor observation found the resident did not have a lunch tray brought to the unit. The resident stated s/he had not eaten dinner the prior day or breakfast or lunch that day and was hungry. A NA confirmed the resident did not receive breakfast and was not fed breakfast or lunch. An LPN stated the resident had been upgraded from tube feeding to a pureed diet the previous afternoon, but the diet order communication form had not been sent to the kitchen, so staff were unaware a tray was needed. The form was not completed until the surveyor brought it to the LPN’s attention, and the Food Service Director confirmed the resident did not receive meals from the kitchen until the communication form was received.
Missed Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice related to a physician's order for weekly skin assessments. The resident was admitted in April 2020 with diagnoses including dementia and multiple sclerosis, and the care plan identified the resident as at risk for pressure injury and skin breakdown related to incontinence and decreased mobility, with an intervention for a licensed nurse to complete a weekly skin assessment. The record did not show completed skin assessments for 2/9/2026, 2/16/2026, 2/23/2026, and 3/2/2026, and the assessment was not completed until 3/4/2026 after the surveyor brought the issue to the facility's attention. During interview, an RN stated the last skin assessment had been completed on 2/2/2026, and the DON was unable to provide evidence that the assessments had been completed as ordered.
Failure to Follow Surgeon’s Wound Vac Order
Penalty
Summary
The facility failed to provide treatment and care in accordance with orders and professional standards for a resident with an open wound of the right back wall of the thorax with penetration into the thoracic cavity. The resident was admitted in February 2026 and had orthopedic spine surgery discharge instructions dated 2/27/2026 to continue wound vac therapy at 125 mmHg negative pressure. That same day, the wound vac was discontinued and changed to a daily dressing, and on 3/1/2026 the surgeon was notified and gave a new recommendation to apply the wound vac to the resident’s back incision with 75 mmHg negative pressure continuously. The record did not show that the surgeon’s updated recommendation was reported to the physician. An integrated wound care note dated 3/2/2026 documented the surgical site and the instruction to apply the wound vac per the surgeon’s recommendation of 75 mmHg, yet surveyor observations on 3/3/2026 and 3/4/2026 found the wound vac still set at 125 mmHg. Staff interviews showed the Unit Manager and Wound Nurse were unaware of the 75 mmHg order, and the DON could not provide evidence that the surgeon’s recommendation had been reported to the provider and followed per facility policy. The wound vac setting was not changed to 75 mmHg until after it was brought to staff attention by the surveyor.
Failure to Maintain Wound Treatment and Weekly Wound Documentation
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer care and weekly wound documentation for a resident with a new facility-acquired Stage III pressure ulcer on the left buttock. The resident had diagnoses including dementia and multiple sclerosis and was identified as at risk for skin breakdown due to incontinence and decreased mobility, with a care plan intervention to provide wound treatment as ordered. The skin and wound evaluation documented the Stage III pressure ulcer measuring 3.2 cm by 1.9 cm, and physician orders were in place for Medi-honey with a dry clean dressing daily from 2/5/2026 through 2/10/2026 and then calcium alginate with bordered gauze starting 2/17/2026. Record review failed to reveal a wound treatment order from 2/10/2026 until 2/17/2026, and there was no evidence that wound care or daily monitoring of the wound was completed during that period. The care plan also required weekly wound assessment with measurements and a description of wound status, but the record lacked wound measurements and descriptions for 2/8-2/14/2026 and 2/22-2/28/2026. During interview, RN Staff C acknowledged there was no wound treatment in place during the gap and that the required wound measurements and descriptions were missing, and the DON was unable to provide evidence that wound care was provided consistent with professional standards.
Unordered Oxygen Therapy and Missing Safety Signage
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents receiving oxygen therapy. Resident ID #9, admitted with diagnoses including congestive heart failure and dementia, was observed on multiple occasions receiving 2 liters of oxygen via nasal cannula. Record review did not reveal a physician's order for oxygen, and during an observation with an LPN present, the resident was again seen receiving oxygen without an order. The LPN acknowledged that the resident was receiving oxygen and did not have a physician's order. Resident ID #80, admitted with diagnoses including respiratory failure and anxiety, was also observed on multiple occasions receiving 2 liters of oxygen via nasal cannula. Record review did not reveal a physician's order for oxygen for this resident either. In addition, cautionary or safety signage was not posted on the room door indicating oxygen use. The Unit Manager and the DNS both acknowledged that the resident was receiving oxygen and did not have a physician's order.
Inaccurate Dialysis Fluid Restriction Monitoring
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis-related fluid management for a resident with end stage renal disease who received dialysis three times a week and had a physician’s order for a 1,200 mL fluid restriction per day. The resident’s care plan identified nutritional risk related to ESRD and dependence on dialysis with a fluid restriction of 1,200 mL and an intervention to monitor intake. Facility policy stated that when a physician orders a fluid restriction, dietary calculates the fluids on meal trays and nursing calculates the remaining amounts for each shift and monitors intake and output. Record review showed that the resident’s intake was not totaled every 24 hours as ordered, and written documents titled Dialysis Fluid Restriction did not match the amounts documented on the MAR for 28 of 28 opportunities in February 2026. The MAR also showed multiple days when documented intake exceeded the ordered fluid restriction, including amounts of 1,320 mL, 2,080 mL, 2,160 mL, and 1,240 mL, and there was no evidence that a provider was notified when the intake was over the ordered limit. During interview, an LPN acknowledged the intake documentation and MAR were inconsistent and stated she wrote what the intake was supposed to be, while the DON and Medical Director stated they would expect fluid intake to be accurately documented and monitored and a provider notified when intake exceeded the restriction.
Delayed Response to Pharmacy Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to address pharmacy recommendations within the required timeframe for 2 of 5 residents reviewed for January pharmacy recommendations. The facility policy titled, Medication Regimen Review and Reporting, stated that the consultant pharmacist reviews each resident’s medication regimen and medical chart at least monthly and that recommendations should be acted upon within 30 calendar days or per facility-specific protocols. For Resident ID #11, who was admitted in July 2025 with diagnoses including post-traumatic stress disorder and anxiety, a pharmacy note dated 1/27/2026 recommended a trial dose reduction for trazodone 75 mg HS, quetiapine 75 mg QAM, and sertraline 150 mg QD. The record did not show that this recommendation was addressed within 30 days per policy. A second pharmacy recommendation for Resident ID #11 dated 2/25/2026 again recommended a trial dose reduction for trazodone 75 mg HS, quetiapine 75 mg QAM, and sertraline 150 mg QD. Documentation later showed the Medical Director agreed with a dose reduction for trazodone 75 mg and no change for the other medications, but the document was undated and the trazodone dose reduction was started on 3/5/2026 after the surveyor brought the issue to the facility’s attention. For Resident ID #52, who was admitted in November 2024 with diagnoses including Parkinson’s and schizophrenia, a nursing recommendation dated 1/30/2026 requested that the Lasix 100 mg daily order be updated to reflect how pharmacy was sending it, changing it to 80 mg plus 20 mg tablets to equal 100 mg. The record did not show that this recommendation was acted on within 30 days, and the DON was unable to provide evidence during interview that the January 2026 pharmacy recommendations had been addressed within the required timeframe.
Medication Error Involving Warfarin Monitoring and Reporting
Penalty
Summary
The facility failed to ensure that a resident receiving warfarin therapy was free from a significant medication error. The resident was admitted with diagnoses including atrial fibrillation and heart failure. A physician ordered a PT/INR laboratory test, and the test was completed, but the result was not communicated to the physician until the following day. Because of the delay in reporting the PT/INR, the resident missed one dose of warfarin. Further review showed that a physician later ordered another PT/INR to be obtained on Monday, but the record did not show that the test was obtained as ordered. During interview, the Unit Manager acknowledged that the resident missed the warfarin dose and that the PT/INR result was not reported to the physician until the next day. The Medical Director stated that he would expect the PT/INR to be obtained and reported in a timely manner so he could review the results to determine the appropriate warfarin dose.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not stored in accordance with currently accepted professional principles in 1 of 2 medication rooms and 1 of 3 medication carts observed. In the Lilly Unit medication room, surveyors observed two bottles of lorazepam 2 mg/ml that were opened and undated, even though the manufacturer’s instructions on the box stated the bottle should be discarded 90 days after opening. RN staff C and LPN staff K acknowledged that the lorazepam was opened and undated. In the Sun Unit medication cart, surveyors observed a bottle of Biotene mouthwash in a pump spray bottle that had no resident identifiers and no cover for the mouth nozzle. The nozzle also had debris and hair on it. CMT staff L acknowledged that the bottle lacked resident identifiers and that the mouth nozzle was dirty. The DON was unable to provide evidence that the facility stored drugs and biologicals in accordance with currently acceptable professional standards.
Failure to Provide Dental Services and Inadequate Denture Loss Policy
Penalty
Summary
The facility failed to provide necessary dental services for a resident with a history of dementia and mild protein calorie malnutrition who was admitted with full upper dentures. Documentation showed that the resident's upper dentures were missing, and staff were unaware that the resident was supposed to have upper dentures. The resident's family reported the missing dentures, and review of the resident's records, including the plan of care and treatment administration record, did not show evidence of assistance or care related to dentures. Interviews with nursing staff revealed uncertainty about whether the resident used dentures, and there was no documentation or physician's order to ensure proper denture care. Additionally, the facility's oral health policy, last reviewed in September, did not include procedures for instances when dentures are lost or damaged, nor did it specify that the facility may not charge residents for such loss or damage as required. The Director of Nursing Services, along with the Administrator and Regional Director, confirmed that the policy lacked this required language and could not provide evidence that the resident received assistance with denture care.
Failure to Maintain Food Safety Standards in Main Kitchen
Penalty
Summary
Surveyor observation, record review, and staff interviews revealed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen. Specific findings included the presence of mold on the walk-in refrigerator walls, dirty racks where food was stored, and food with mold that reportedly went unnoticed for weeks. During a kitchen tour, surveyors observed multiple food items in the walk-in refrigerator that were not properly labeled or dated, including a pan of red beans, fried rice, roasted potato wedges, and tomato soup, all of which were past their discard dates or had illegible labels. Additionally, a pan of red liquid had an illegible label, and there were approximately a dozen orange juice containers that were sticky, wet, and included one open, leaking container. Three broken eggs were also found, with their contents covering the inside of a box containing several dozen whole, raw eggs. The Regional Food Service Director acknowledged that the observed food items should have been discarded after seven days and should have had legible labels with the contents and preparation dates. The Director also confirmed that the leaking orange juice container and broken eggs should have been discarded. The facility Administrator acknowledged the findings in the main kitchen during a subsequent interview. These observations and acknowledgments indicate a failure to adhere to the 2022 FDA Food Code requirements for package integrity and date marking of ready-to-eat, time/temperature control for safety foods.
Failure to Prevent Accidents and Implement Fall Interventions
Penalty
Summary
The facility failed to ensure adequate care and supervision to prevent accidents for two residents. In the first case, a resident with Alzheimer's disease, dementia, and mobility issues sustained a large, deep wound to the left lower leg during a transfer and required hospital evaluation and sutures. Documentation showed the resident required assistance and the use of a walker and gait belt for transfers, as outlined in the facility's Safe Resident Handling/Transfer Equipment policy. However, staff interviews revealed that the transfer was performed without a walker or gait belt, and the staff member assisting was not assigned to the resident and did not remove the resident's clothing, which delayed the discovery of the injury. In the second case, another resident with dementia, muscle weakness, a history of falls, and severe cognitive impairment experienced an unwitnessed fall resulting in a left hip fracture. Prior to this, the resident had a bruise on the left bicep, and a Change in Condition evaluation was completed, but no new fall prevention interventions were implemented as required by the facility's Falls Management policy. Staff interviews confirmed that after the unwitnessed fall and identification of the bruise, no additional interventions were put in place to address the resident's increased fall risk. Both incidents demonstrate a failure to follow established facility policies for safe resident handling and falls management. The lack of proper transfer techniques and failure to update care plans with new interventions after a fall directly contributed to the residents' injuries.
Failure to Honor Resident's Right to Refuse Medication
Penalty
Summary
A resident with diagnoses including cerebral palsy and dysarthria, and with intact cognition as evidenced by a Brief Interview for Mental Status score of 15/15, reported being held down by staff after refusing medications. The resident, who is able to make their needs known but has impaired communication, was admitted with orders allowing medications to be given by mouth if the G-tube was inaccessible. On the date in question, documentation and staff interviews revealed that the resident was combative and refused medications multiple times. Despite this, staff proceeded to administer medications via the resident's G-tube after the resident's repeated refusals. Staff interviews confirmed that a nursing assistant assisted by distracting or holding the resident while a nurse administered the medications. The resident later verbally stated to the surveyor that they had said no repeatedly and did not want the medications, expressing distress over being held down. The Director of Nursing and Administrator confirmed that facility policy requires staff to respect a resident's right to refuse medication and to notify the provider in such cases, which was not followed in this incident.
Deficiencies in Kitchen Cleanliness and Chemical Labeling
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in the main kitchen, as observed by surveyors. During an initial tour, surveyors noted several cleanliness issues, including an accumulation of black matter on the walls of the main kitchen and dish room, a fan in the dish room with approximately one inch of dust and debris, and a floor drain in front of the steamer with about 1.5 inches of thick, grayish-black grime. These observations indicate a failure to maintain nonfood contact surfaces free of dirt, dust, food residue, and other debris, as required by the Rhode Island Food Code 2018 Edition. Additionally, the facility did not comply with labeling requirements for chemical products. A spray cleaning bottle containing a pink substance was found without a label that included a signal word or a statement indicating that full label information was available, as required by the State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities and the Occupational Safety and Health Administration Standard 1910.1200. The Regional Executive Chef acknowledged the need for cleaning the walls, ceiling fan, and floor drain, as well as the labeling deficiency of the spray cleaning bottle.
Failure to Monitor Dialysis Care and Fluid Restrictions
Penalty
Summary
The facility failed to provide appropriate dialysis care for two residents requiring such services. Resident ID #32, who has end-stage renal disease and relies on outpatient dialysis, was not properly monitored for the bruit and thrill of their arteriovenous fistula, with assessments missed on 95 out of 96 opportunities. Additionally, there was a discrepancy in the resident's MOLST form regarding their resuscitation status, which was not updated in the dialysis communication binder. Furthermore, the facility did not implement or monitor a fluid restriction for the resident until it was identified during the survey process. Resident ID #11, diagnosed with stage 4 chronic kidney disease, also received outpatient dialysis but was not monitored for their prescribed daily fluid restriction of 1500 mL. Observations revealed the resident had access to fluids exceeding their restriction, and there was no documentation of fluid intake monitoring until the issue was highlighted by surveyors. Interviews with staff confirmed the lack of monitoring and documentation for both residents' fluid intake, which is critical for their dialysis care.
Failure to Adhere to Medication Parameters for Midodrine Administration
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically regarding the administration of Midodrine. The resident, who was readmitted to the facility in July 2023 with diagnoses including dementia and hypotension, had a physician's order for Midodrine to be administered with specific parameters. The order specified that the medication should be held if the resident's systolic blood pressure (SBP) was greater than 120. However, a review of the Medication Administration Records for November and December 2024 revealed multiple instances where the resident was administered Midodrine despite having an SBP exceeding the specified parameter. Interviews conducted during the survey revealed that the facility staff, including a registered nurse and the Director of Nursing Services, acknowledged the failure to adhere to the physician's order. The resident's physician was also unaware that the medication was being administered outside the prescribed parameters and expressed an expectation that the staff would follow the order as written. This oversight indicates a lapse in the facility's medication administration process, leading to the administration of unnecessary drugs to the resident.
Failure in Antibiotic Stewardship and Monitoring
Penalty
Summary
The facility failed to establish an effective Infection Prevention and Control Program (IPCP) that includes an antibiotic stewardship program, as evidenced by the lack of antibiotic time-outs for two residents. Resident ID #23 was readmitted with sepsis and a urinary tract infection and was prescribed Amoxicillin. However, there was no evidence of an antibiotic time-out being conducted to reassess the need for the antibiotic. Similarly, Resident ID #27, admitted with an infection of the intervertebral disc, was prescribed Ciprofloxacin for a wound infection, but again, no antibiotic time-out was documented. This failure was acknowledged by the Director of Nursing Services, the Infection Preventionist, the Administrator, and the Market Lead Clinical Specialist during a surveyor interview. Additionally, the facility did not have a tracking system for antibiotic use, including days of therapy, as recommended by the CDC's Core Elements of Antibiotic Stewardship for Nursing Homes. The record review of the facility's IPCP did not reveal any evidence of such a tracking system. During an interview, the Infection Preventionist and the Director of Nursing Services admitted they were unaware of the antibiotic days of therapy and did not track them, indicating a gap in monitoring and evaluating antibiotic use within the facility.
Failure to Accommodate Resident Meal Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of two residents, leading to deficiencies in meal service. Resident ID #28, who was admitted with a diagnosis including anxiety disorder and has intact cognition, expressed a dislike for eggs and a preference for pancakes. Despite this, the resident continued to receive eggs during meals. On a specific occasion, the resident was served two boiled eggs instead of the preferred pancakes, as indicated on the meal ticket. The Registered Nurse, Staff B, was unable to explain why the resident's preferences were not followed, indicating a lapse in the dietary aides' adherence to the meal ticket instructions. Similarly, Resident ID #30, who was admitted with a diagnosis including depression and also has intact cognition, did not receive the meal ordered. The resident's meal ticket indicated a preference for a shredded pork sandwich and coleslaw, but instead, a turkey patty was served. The resident reported that this was a recurring issue, with meals often not matching the orders. The Regional Executive Chef acknowledged the discrepancy and confirmed that the meal tickets should reflect the residents' actual meal preferences, highlighting a failure in the facility's meal service process.
Failure to Ensure Residents' Right to be Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints not required to treat medical symptoms. This deficiency was identified for two residents, who were restrained without proper assessments, consent, or physician orders. The facility's policy on restraints clearly states that patients have the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the patient's medical symptoms. However, the facility did not adhere to this policy, as evidenced by the incidents involving the two residents. Resident ID #2 was observed in a recliner chair with multiple obstructions preventing safe exit, including a wall, a table, a chair under the footrest, and another resident's recliner behind. Video footage showed that staff members physically restrained Resident ID #2 by pushing a table against the resident's chest and wedging it between the resident and a support column. Additionally, another resident, Resident ID #7, was also restrained in a recliner chair in a manner that prevented independent movement. Both residents were severely cognitively impaired and required assistance for mobility, yet there were no documented restraint assessments, consent forms, or physician orders for these restraints. Interviews with staff members revealed that the practice of restraining residents in this manner was common due to concerns about fall risks. Staff members admitted to restraining residents under the direction of a Licensed Practical Nurse (LPN), who acknowledged allowing this practice due to safety concerns and inadequate monitoring by staff. The facility's administration confirmed the use of physical restraints on the residents and acknowledged the lack of proper documentation and adherence to the facility's restraint policy.
Failure to Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to provide evidence that all alleged violations of abuse were thoroughly investigated and reported to the State Survey Agency. An incident involving Resident ID #1 occurred on 4/24/2024, where the resident was overheard screaming for help and accusing staff members of hitting them. Despite the immediate report of the incident to a Licensed Practical Nurse (LPN), there was no evidence that the allegation was acted upon immediately. This failure allowed the alleged perpetrators to continue working that evening, leading to another abuse allegation involving Resident ID #2 approximately five hours later. The facility did not begin investigating the initial allegation until 5/1/2024, seven days after the incident occurred. Resident ID #1, who has diagnoses including dementia and anxiety disorder, was admitted to the facility in May 2023. The resident's Minimum Data Set (MDS) assessment indicated severe cognitive impairment. On 4/24/2024, before dinner, the resident was heard screaming for help and accusing staff members of hitting them. Staff members who overheard the incident reported it to the LPN on duty, but there was no immediate action taken to investigate or remove the alleged perpetrators from duty. This inaction allowed the staff members to continue working, resulting in another abuse incident involving Resident ID #2 later that evening. Resident ID #2, admitted in March 2024 with diagnoses including dementia and cognitive communication deficit, was also severely cognitively impaired. On the same evening, staff members were observed physically abusing and restraining Resident ID #2 in the day room. The incident was captured on video footage, which was reviewed by the Administrator and Director of Nursing Services (DNS) on 4/26/2024. The facility's failure to act on the initial abuse allegation involving Resident ID #1 allowed the same staff members to continue working and subsequently abuse Resident ID #2. The Administrator was not made aware of the initial allegation until 5/1/2024, further highlighting the delay in addressing the abuse reports.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse. On 4/24/2024, a Nursing Assistant (NA) and a Certified Medication Technician (CMT) were observed physically abusing and restraining a resident with severe cognitive impairment. The abuse was reported by another NA who overheard the incident and observed the resident being mistreated. Video footage confirmed the aggressive actions of the staff members, including shoving the resident and restraining them with a table against their chest. The resident, who has dementia and a cognitive communication deficit, was admitted to the facility in March 2024. The resident was unable to communicate effectively and was considered severely cognitively impaired. The incident occurred in the day room, where the resident was initially seated in a recliner and later moved to a wheelchair. The staff members involved were seen on video footage aggressively handling the resident, causing physical harm and distress. Interviews with staff members revealed that the abusive actions were not isolated incidents. The staff admitted to restraining the resident as a means of preventing falls, as directed by a Licensed Practical Nurse (LPN). The resident was found with multiple bruises on their arms and legs, indicating ongoing physical abuse. The facility's Administrator and Director of Nursing Services (DNS) acknowledged the failure to protect the resident from abuse and took disciplinary actions against the involved staff members.
Failure to Address Resident Abuse and Rights
Penalty
Summary
The facility's Quality Assessment and Assurance Improvement (QAPI) committee failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to resident abuse and resident rights. On multiple occasions, the facility received deficiencies for failing to protect residents from abuse and failing to report allegations of abuse in a timely manner. Specifically, on 1/24/2024, a housekeeper was observed kissing a resident, and the incident was not reported promptly. On 2/19/2024, staff failed to provide incontinence care, which was also not addressed adequately. Despite providing education to nursing staff, the facility did not develop a comprehensive plan to monitor and evaluate performance indicators to ensure sustained corrections or necessary revisions. Further incidents occurred on 4/24/2024, where a Nursing Assistant reported allegations of abuse involving two staff members and two residents. One resident was heard yelling and a bang noise was reported, while another resident was overheard screaming for help and pleading not to be hit. The facility failed to act immediately on these allegations, allowing the involved staff members to continue working. During an interview, the Administrator and Director of Nursing Services admitted that they had only provided education to nursing staff and had not developed a QAPI plan to monitor and evaluate performance indicators. This failure led to Immediate Jeopardies, as the facility did not keep residents free from physical abuse and restraints, nor did it report and investigate allegations of abuse promptly.
Failure to Ensure Staff Competency in Restraint Use
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies to provide safe care, as evidenced by an incident involving the physical restraint of two residents. On 4/24/2024, video footage showed that a nursing assistant and a certified medication technician restrained Resident ID #2 by placing a table against the resident's chest and positioning another resident's recliner to block movement. This method of restraint was acknowledged by the facility's administration and was reportedly used frequently to prevent falls, despite being inappropriate and unsafe. Additionally, Resident ID #7 was also restrained in a manner that prevented independent movement. The facility's records revealed that several staff members, including those involved in the incident, had not completed mandatory training on restraint and seclusion. This lack of training was confirmed during interviews with the facility's administration and the regional nurse. The facility's assessment indicated that education on physical restraints was provided, but there was no evidence that the required training had been completed by the staff members involved in the incident.
Pharmacist Failed to Report Drug Regimen Irregularities
Penalty
Summary
The pharmacist failed to report irregularities in the drug regimen review for a resident admitted in January 2021 with diagnoses including dementia, anxiety, and depression. The resident had a physician's order for Lorazepam Oral Concentrate 2 MG/ML, to be administered as needed for seizures lasting more than 5 minutes, without an end date or documented rationale for extending the duration of use. The resident received the medication once in May 2024. The pharmacist's consultation reports from December 2023 to April 2024 did not identify the missing end date. During an interview, the pharmacist confirmed the completion of the consultation reports but could not provide evidence that the irregularity was reported to the attending physician, the Medical Director, and the DNS as required.
Failure to Ensure Drug Regimen Free from Unnecessary Psychotropic Drugs
Penalty
Summary
The facility failed to ensure a resident's drug regimen was free from unnecessary psychotropic drugs. The resident, admitted in January 2021 with diagnoses including dementia, anxiety, and depression disorder, had a physician's order dated December 1, 2023, for Lorazepam Oral Concentrate 2 mg/ml, to be given 1 ml by mouth every 24 hours as needed for a seizure lasting more than 5 minutes. However, the order lacked an end date or a documented rationale for extending the duration of use. The resident received the medication on May 1, 2024, despite not having a diagnosis of a seizure disorder or any history of seizure activity. The medication was administered because the resident was scratching their arms, which was not the intended purpose of the medication order. During interviews, the LPN who administered the medication confirmed that the resident did not have a seizure disorder and that the medication was given for scratching. The Director of Nursing Services acknowledged that the order had no end date and that the medication was administered for an incorrect purpose. This failure to adhere to proper medication protocols resulted in the resident receiving unnecessary psychotropic medication.
Failure to Complete Mandatory Communication Training
Penalty
Summary
The facility failed to ensure that all direct care staff completed mandatory effective communication training for 5 out of 7 staff reviewed. Specifically, there was no evidence that Staff D, E, G, H, and I completed the required training for 2023. Staff D, a Nursing Assistant (NA), was hired on 9/22/2009; Staff E, a Certified Medication Technician, was hired on 8/18/2009; Staff G, an NA, was hired on 6/12/2022; Staff H, an NA, was hired on 10/6/2016; and Staff I, an NA, was hired on 6/10/2016. During an interview with the Regional Nurse, in the presence of the Administrator and Director of Nursing Services, they were unable to provide evidence that the training was completed for these staff members.
Failure to Provide Mandatory QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training to all staff on the elements and goals of the Quality Assurance and Performance Improvement (QAPI) program. Record review revealed that five out of seven staff members reviewed, specifically Staff D, E, G, H, and I, did not complete the required QAPI training for 2023. Staff D, a Nursing Assistant (NA), was hired on 9/22/2009; Staff E, a Certified Medication Technician, was hired on 8/18/2009; Staff G, an NA, was hired on 6/12/2022; Staff H, an NA, was hired on 10/6/2016; and Staff I, an NA, was hired on 6/10/2016. During an interview with the Regional Nurse, Administrator, and Director of Nursing Services, they were unable to provide evidence that the training was completed for these staff members.
Failure to Provide Mandatory Compliance and Ethics Training
Penalty
Summary
The facility failed to provide mandatory training on compliance and ethics to all their staff, as required. Record review revealed that five out of seven staff members reviewed did not complete the necessary training for 2023. The staff members identified were Staff D, E, G, H, and I, who were hired on various dates ranging from 2009 to 2022. During an interview with the Regional Nurse, in the presence of the Administrator and Director of Nursing Services, it was confirmed that there was no evidence of completed training for these staff members.
Failure to Provide Behavioral Health Training
Penalty
Summary
The facility failed to provide mandatory behavioral health training to five out of seven staff members reviewed. Specifically, there was no evidence that Staff D, E, G, H, and I completed the required training for 2023. Staff D, a Nursing Assistant (NA), was hired on 9/22/2009; Staff E, a Certified Medication Technician, was hired on 8/18/2009; Staff G, an NA, was hired on 6/12/2022; Staff H, an NA, was hired on 10/6/2016; and Staff I, an NA, was hired on 6/10/2016. During an interview with the Regional Nurse, Administrator, and Director of Nursing Services on 5/6/2024, it was confirmed that the facility could not provide evidence of completed training for these staff members.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to treat two residents with respect and dignity, as observed in video footage and confirmed through staff interviews. Resident ID #2 was seen in a recliner chair wearing only a hospital gown, with their upper thighs and legs exposed while being transported by a Nursing Assistant (NA), Staff D. Staff D did not attempt to cover the resident during the transport. Additionally, Staff D was observed aggressively handling Resident ID #2's arms and pushing a table against the resident's chest, causing the table to be wedged between the resident and a support column. Resident ID #2 has severe cognitive impairment, as indicated by their inability to complete a Brief Interview for Mental Status (BIMS) assessment due to being rarely/never understood. The resident was admitted to the facility in March 2024 with diagnoses including dementia and cognitive communication deficit. Resident ID #7 was observed lying in a recliner chair in the day room, appearing to be in and out of sleep with their head hanging over the side of the chair. This resident also has severe cognitive impairment, as indicated by their inability to complete a BIMS assessment. The resident was readmitted to the facility in February 2024 with diagnoses including dementia, cerebral infarction (stroke), and agitation. Staff interviews revealed that both residents are often left in the day room for extended periods without proper monitoring, especially when staff are on their phones. The facility's Administrator and Director of Nursing Services acknowledged the failure to treat these residents in a dignified manner and in an environment that promotes their quality of life.
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The facility failed to follow physician orders for post-fall care for three anticoagulated residents who experienced falls. One resident on a blood thinner with a head injury was ordered to be transferred to the ED after a telehealth evaluation, but an LPN did not send the resident, citing instructions to contact a supervisor first and inability to reach that supervisor. For two other residents on anticoagulants, providers ordered intensive neuro checks (every 15 minutes, then every 30 minutes, then hourly, then every 4 hours), but staff instead performed neuro checks only once per shift for 72 hours. The DON and Medical Director acknowledged that the transfer and monitoring orders were not implemented as written.
A resident with intact cognition and psychiatric diagnoses sustained a left eyebrow laceration when another resident with a documented history of escalating aggressive and threatening behaviors struck them with a cane during a hallway dispute. The aggressive resident had multiple prior documented incidents, including verbal threats to kill others, attacking a roommate with a cane over TV volume, throwing objects during activities, and throwing a lunch plate at staff. Despite these events, the care plan was not updated with interventions to address physical aggression toward other residents, and a psychiatric recommendation for PRN trazodone for agitation, anxiety, and insomnia was only implemented as PRN for insomnia. The failure to assess, monitor, and implement effective interventions for the aggressive resident’s behaviors led to the assault and injury and, per the report, placed this and other residents at risk of serious physical and psychosocial harm.
A resident with impulse disorder, mood and anxiety diagnoses, and a history of escalating verbal and physical aggression had multiple documented incidents of threats, object throwing, and assault with a cane. Despite a psychiatric consult recommending PRN trazodone for agitation, anxiety, and insomnia, the provider order listed insomnia only, and the care plan was not updated with specific interventions to address the resident’s physically aggressive behaviors after several documented events. Subsequently, the resident struck another resident with a cane, causing a facial laceration that required wound closure and ongoing treatment.
The facility failed to properly screen and document clearance for a NA with disqualifying criminal history information before hire, as required by its abuse, neglect, and exploitation policy. A BCI check showed disqualifying information, yet the NA was hired, completed orientation, and worked independently based only on verbal disclosure of an old drug-related charge, without written details or verification. Later, a staff member reported witnessing this NA grab a resident’s face and kiss the resident on the lips, and a community complaint alleged inappropriate interactions with the same resident, prompting involvement of local police.
A resident with anxiety disorder and PTSD was unable to attend meals and activities with peers because the facility lost the resident's clothing after it was sent to laundry. The resident was observed in a hospital gown with only a few clothing items in the room, and the record lacked an admission inventory of belongings. The DON/Administrator reported that laundry was handled by an outside vendor without a tracking system or item documentation.
A resident with dementia and severely impaired cognition was subjected to repeated non-consensual kissing on the lips by an NA, who entered the resident’s room during care, verbally expressed affection, and then kissed the resident on the mouth on at least two separate occasions witnessed by staff. One staff member delayed reporting the first incident due to fear of the NA. These actions occurred despite a facility policy defining sexual abuse as any non-consensual sexual act and requiring protections of residents’ rights and well-being.
Failure to investigate allegations of resident-to-resident sexual inappropriateness: A resident with dementia and TBI was documented as being inappropriate with another resident, and psych notes later described increased sexually inappropriate behaviors toward other residents. Staff interviews showed the resident had been observed touching others and needing frequent redirection, but the DON, ADON, and Administrator acknowledged the facility did not complete an investigation or recognize the allegation as possible abuse.
A resident with dementia and a hearing deficit did not receive ear care as ordered because the chart lacked the Debrox order and the ear was flushed before the intended Debrox course was completed. In a separate incident, staff witnessed inappropriate kissing of a resident with dementia, but the allegation was not reported to the provider and the care plan was not updated. A third resident’s wound care was also not completed as ordered when an RN used normal saline instead of the prescribed Vashe wound wash.
A resident with migraines and chronic pain did not receive timely pain management after repeatedly reporting a migraine and appearing in visible distress. An NA notified an LPN, an RN said she could not access the med cart, and the resident continued waiting while the LPN was off the unit; the PRN migraine medication was not given until 40 minutes after the first complaint. The DON acknowledged the resident should not have waited that long for pain medication.
A resident missed 6 doses of a prescribed antibiotic, and the MAR did not show that the provider was notified. The RN acknowledged the missed doses and said they should have been reported, while the Medical Director stated she was unaware of the missed doses and would have extended the antibiotic course if informed. The DON also confirmed the missed doses and expected provider notification for any missed antibiotic dose.
Failure to Follow Post-Fall Physician Orders for Anticoagulated Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement physician orders for post-fall care, including hospital transfer and neurological monitoring, for residents on anticoagulant therapy. One resident with atrial fibrillation on Xarelto experienced an unwitnessed fall with a scalp laceration and head lump. The on-call provider, after a telehealth evaluation, ordered transfer to the ED and wrote an order directing that the resident be sent to the hospital. The resident was not transferred as ordered, and an additional order for vital signs and neuro checks every shift for 72 hours after the fall was not completed as ordered on one of the shifts. The LPN caring for this resident stated she did not send the resident to the ED because she had been instructed to call a supervisor before sending residents out, and she was unable to reach the supervisor during the shift. A second resident, also with atrial fibrillation and on Xarelto, had an unwitnessed fall with injury. The on-call provider was notified and ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, then every four hours for an additional 24 hours. A physician’s order reflecting this schedule was scanned into the EMR. However, the neuro checks were not completed as ordered; instead, they were performed only once per shift for 72 hours. The RN who authored the progress note documented the fall and the resident’s anticoagulant use, and later stated she could not remember why she did not transcribe and complete the neuro checks as ordered. A third resident with atrial fibrillation on Apixaban had a non-injury fall after attempting to walk independently. The on-call provider ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, and then every four hours for an additional 24 hours, and this order was scanned into the EMR. The record did not show that these neuro checks were completed as ordered; instead, neuro checks were documented only once per shift for 72 hours. The Medical Director stated he would have expected the first resident to be transferred to the ED as ordered and that the facility should not override a provider’s order. The DON acknowledged that the transfer order and the ordered monitoring for the first resident were not followed as written, and that for the second and third residents, staff performed only once-per-shift neuro checks instead of the more frequent monitoring ordered by the providers.
Failure to Manage Escalating Aggression Leading to Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident, Resident ID #1, from abuse by another resident with a known history of escalating aggression, Resident ID #2. Resident ID #1 was admitted in October 2025 with diagnoses including paranoid schizophrenia and adjustment disorder with mixed anxiety and depressed mood, and had a BIMS score of 14/15, indicating intact cognition. On 4/27/2026, progress notes documented that Resident ID #1 was on the receiving end of a physical altercation with another resident and was found with a deep bleeding abrasion to the left eyebrow. A subsequent nursing note described a new laceration to the left eyebrow measuring 0.5 cm by 2.0 cm by 0.1 cm, related to a resident-to-resident incident, for which wound closure strips were applied. Resident ID #1 requested police involvement and a police report, and refused transfer to the hospital for sutures. Resident ID #2 had been admitted in December 2024 with multiple psychiatric and behavioral diagnoses, including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed a BIMS score of 13/15 and documented both physical and verbal behaviors during the look-back period. Progress notes over several months recorded a pattern of escalating aggressive and threatening behaviors: on 9/13/2025, Resident ID #2 threatened to slit another resident’s throat and made additional threats toward staff; on 11/7/2025, the resident was involved in a verbal dispute with raised voice, name-calling, and verbal threats; on 12/28/2025, after another resident struck Resident ID #2 with a helmet, Resident ID #2 was overheard threatening to kill that resident if touched again. On 2/21/2026, the on-call provider documented that Resident ID #2 attacked a roommate with a cane over TV volume and required ER transfer for psychiatric evaluation. Subsequent notes on 3/9/2026 and 4/10/2026 described the resident throwing poker chips on the floor, yelling and swearing at staff and residents, and throwing a lunch plate across the nurses’ station at a nursing assistant due to dissatisfaction with portion size. Despite this documented pattern, the care plan for Resident ID #2, dated 1/16/2025, only indicated a behavior problem of being verbally aggressive toward staff with resident-to-resident altercations on 12/28/2025, 2/21/2026, and 4/27/2026, and record review failed to show added interventions to mitigate the risk of physical aggression toward other residents after the 2/21/2026 cane attack and the object-throwing incidents on 3/9/2026 and 4/10/2026. A psychiatric evaluation on 4/23/2026 recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order entered on 4/24/2026 specified trazodone 25 mg twice daily as needed only for insomnia, and record review did not show that agitation and anxiety were included as indications for use. During interviews, the RNP and the DON stated it was their expectation that agitation and anxiety would have been included in the trazodone order, and the DON was unable to provide evidence that the care plan had been updated with interventions to address Resident ID #2’s physically aggressive behaviors documented on 2/21/2026, 3/9/2026, and 4/10/2026. On 4/27/2026, the DON documented that Resident ID #2 was ambulating down the hall toward his/her room while Resident ID #1 was walking in the opposite direction, and the two residents began a verbal dispute. Before staff could intervene, Resident ID #2 used his/her cane to make contact with Resident ID #1, resulting in the eyebrow laceration that required steri-strips and ongoing wound treatment. A police incident report recorded that Resident ID #1 stated being struck with a walking cane, wanted to press charges, and that Resident ID #2 admitted to striking Resident ID #1, leading to an arrest on one count of felony assault with a dangerous weapon. The facility’s failure to assess, monitor, and implement effective interventions for Resident ID #2’s known and escalating aggressive behaviors, including failure to update the care plan after prior incidents and failure to fully implement psychiatric recommendations, resulted in this resident-to-resident altercation and injury, and the report states that this failure placed Resident ID #1 and other residents at risk of serious physical and psychosocial harm.
Failure to Implement Psychiatric Recommendations and Update Behavior Care Plan Leading to Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health services and care planning for a resident with a documented history of psychiatric conditions and aggressive behaviors. The resident was admitted in December 2024 with diagnoses including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed intact cognition with a BIMS score of 13/15 and documented physical and verbal behaviors during the look-back period. Over time, multiple behavioral incidents were recorded, including threats to slit another resident’s throat during a smoking session, verbal disputes with name-calling and threats, and a statement to another resident that if touched again the resident would be killed. Further documentation showed escalating behaviors, including an incident where the resident attacked a roommate with a cane over television volume and required ER transfer for psychiatric evaluation, throwing poker chips and yelling when not winning at Bingo, causing the roommate to avoid the shared bathroom due to inappropriate comments and frustration over the light being turned on at night, and throwing a lunch plate across the nurses’ station at a nursing assistant over portion size. The care plan, initiated in January 2025 for verbal aggression and resident-to-resident altercations, did not contain added interventions to address the resident’s physically aggressive behaviors toward others after the incidents on 2/21/2026, 3/9/2026, and 4/10/2026. The DNS later could not provide evidence that the care plan had been updated with interventions to mitigate the risk of these physically aggressive behaviors or to guide staff in ensuring the safety of other residents. On 4/23/2026, a psychiatric evaluation recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order dated 4/24/2026 implemented trazodone 25 mg twice daily as needed for insomnia only, and the record lacked evidence that agitation and anxiety were included as indications for use as recommended by the consulting psychiatrist. Both the RNP and the DNS stated it was their expectation that the trazodone order would have included agitation and anxiety. Following this incomplete implementation of the psychiatric recommendation and the lack of updated behavioral interventions in the care plan, a resident-to-resident altercation occurred on 4/27/2026 in which the resident struck another resident with a cane, causing a laceration to the left eyebrow that required closure with steri-strips and ongoing wound treatment.
Failure to Properly Screen and Clear NA with Disqualifying Criminal History
Penalty
Summary
The facility failed to ensure that a prospective employee was properly screened and cleared for a history of abuse, neglect, exploitation, or misappropriation of resident property before hire. A nursing assistant, identified as Staff A, was hired on 11/18/2025 and was working independently as a NA. Prior to hire, a Bureau of Criminal Identification (BCI) check dated 11/6/2025 showed that Staff A had disqualifying information under federal and state law. Surveyor review after discovery of the positive BCI revealed that Staff A had an extensive criminal history. Despite this, the facility proceeded with the hire and allowed Staff A to complete orientation and work independently without obtaining or maintaining documentation specifying the nature of the disqualifying information, contrary to the facility’s Abuse, Neglect and Exploitation Policy, which requires screening and documentation of proof that such screening occurred. Subsequently, a facility-reported incident submitted on 4/17/2026 documented that a staff member reported witnessing Staff A grab a resident’s face and kiss the resident on the lips. A community-reported complaint submitted on 4/22/2026 alleged inappropriate interactions between the same NA and the same resident, and included a local police incident report indicating the resident’s family intended to pursue charges related to the incident. During interviews, the Human Resource Director stated that Staff A had disclosed disqualifying information related to a prior drug-related charge from about ten years earlier, but acknowledged there was no documentation specifying the nature of the disqualifying information and that this was known only by word of mouth. The Administrator stated she was aware that the BCI contained disqualifying information and that she exercised her own judgment in proceeding with the hire, and further acknowledged she did not receive documentation detailing the disqualifying information until it was brought to her attention by the surveyor.
Failure to Maintain Resident Clothing and Dignity
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity when the resident was unable to attend meals and activities with other residents because of a lack of appropriate clothing. The resident was admitted in May 2025 with diagnoses including anxiety disorder and post-traumatic stress disorder, and a care plan revised on 8/25/2025 described the resident as highly social and willing to participate in a variety of activities, with an intervention to provide reminders of scheduled events. During observation on 4/29/2026, the resident was found in the room wearing a hospital gown while other residents were in the dining room for lunch. Only one pair of pants and two T-shirts were observed in the room. The resident stated that the facility lost all of the resident's clothing, including shirts, pants, shorts, and socks, after they were sent to laundry services several months earlier and were never returned. The resident reported that the Administrator was told about the missing clothing, but no follow-up occurred and the clothing was neither located nor replaced. The record did not contain an admission inventory list of the resident's belongings, and the Administrator stated that laundry was handled by an outsourced company without a tracking system or documentation identifying which items belonged to which resident.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse when a nursing assistant (NA) was observed kissing the resident on the lips on more than one occasion. The resident, identified as having dementia and a Brief Interview for Mental Status (BIMS) score of 0/15 indicating severely impaired cognition, had been admitted in March 2026. On one occasion, a Certified Medication Technician (CMT) reported that while she was assisting the resident with breakfast, the NA entered the room, verbally expressed affection for the resident, made a kissing noise, leaned forward, and kissed the resident on the lips. This incident made the CMT uncomfortable, and she later discussed it with another NA. A separate staff member, another NA, reported that two days earlier she had observed the same NA enter the resident’s room while morning care was being provided, ask the resident if they remembered her, state that she loved the resident, then lean toward the resident, make a kissing sound, and kiss the resident on the mouth with full lip-to-lip contact. This second NA did not report the incident at the time because she was fearful of the NA involved and only came forward after learning of the later incident. The facility’s abuse, neglect, and exploitation policy defined sexual abuse as a non-consensual sexual act of any type with a resident and required protections for each resident’s health, welfare, and rights, as well as screening of potential employees for a history of abuse. Despite this policy, the resident with severely impaired cognition was subjected to repeated non-consensual kissing by the NA.
Failure to Investigate Allegations of Resident-to-Resident Sexual Inappropriateness
Penalty
Summary
The facility failed to ensure that allegations made by residents were recognized as possible abuse by staff and that all allegations were investigated for Resident ID #41, who was admitted with diagnoses including dementia and traumatic brain injury. A facility policy titled, Abuse, Neglect and Exploitation, stated that an immediate investigation is warranted when suspicion of abuse, neglect, exploitation, or reports of abuse, neglect, or exploitation occur. A progress note written by an RN documented that a resident reported Resident ID #41 was being inappropriate with another resident. Subsequent records included psychiatric evaluations stating the resident was being seen due to increased sexually inappropriate behaviors toward other residents and that sexual impulses may present an unsafe environment for other patients in the facility. Staff interviews revealed that Resident ID #41 had been observed touching other residents' shoulders and hands and required frequent redirection. The RN who documented the incident stated the behavior involved an attempted hug without contact and that both residents were separated and assessed, while the ADON and DON acknowledged they were unaware of the behavior or that the facility had not investigated the allegations. The Administrator also acknowledged that an investigation had not been completed to determine what sexually inappropriate behavior had occurred and that staff did not identify the allegation as possible abuse or investigate it immediately.
Failure to Follow Orders, Report Abuse, and Perform Ordered Wound Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for a resident with dementia and anxiety disorder who had a hearing deficit and complained of right ear wax buildup. The medical record showed an order for Debrox ear drops and a separate order to flush the right ear with warm water two times a day following Debrox usage for 5 days, but the record did not include a physician order for the Debrox solution. The April 2026 MAR showed the resident’s right ear was flushed six times, and the resident stated that the right ear still felt blocked. The RN acknowledged flushing the ear and was unaware whether Debrox had been given, while the DON stated the order had been entered incorrectly and that the ear should not have been flushed before Debrox administration. The NP stated the intended order was for Debrox twice daily for five days before irrigation and that she would not have ordered daily ear flushing. The facility also failed to report an allegation of abuse and failed to update the care plan for a resident with dementia after staff reported inappropriate interactions with a nursing assistant. A community complaint and police incident report indicated the family wanted to press charges, and the Administrator and DON confirmed that staff had reported witnessing the nursing assistant kiss the resident on two occasions. The record did not show that the allegation was reported to the provider, and the comprehensive care plan was not updated to reflect the allegation or any interventions related to the incident. The NP stated she was unaware of the incident and would have expected to be notified, and the ADNS acknowledged that the provider had not been notified and the care plan had not been updated. The facility further failed to follow a wound care order for a resident readmitted with peripheral vascular disease and cellulitis of the lower limb. The physician ordered cleansing open areas on the left lower leg with Vashe wound wash, applying xeroform to the wound bed, and wrapping with kling. During observation, the RN performing wound care did not use Vashe wash and instead cleansed the wound with normal saline. The RN acknowledged using normal saline rather than the ordered cleanser, and the DON stated she would expect the nurse to follow the wound orders as written.
Delayed Pain Medication for Resident with Migraine
Penalty
Summary
Safe, appropriate pain management was not provided for Resident ID #17, who was admitted with diagnoses including migraines and chronic pain. The resident’s care plan dated 4/20/2026 included a goal for the resident to verbalize adequate pain relief and an intervention to respond immediately to any complaint of pain. The physician ordered Butalbital-APAP-Caffeine 50-300-40 mg, 1 capsule every 12 hours as needed for migraine pain. On 4/29/2026 at 10:30 AM, the resident was observed in the hallway complaining of a migraine, moaning in pain, and holding his/her head. At 10:34 AM, an NA reported to an LPN that the resident wanted pain medication, and at 10:37 AM the resident continued to complain of migraine pain and told an RN about the pain, but the RN stated she did not have keys to the medication cart and could not get any pain medication. The resident continued to complain of severe head pain, returned to the room to lie down at 10:40 AM, and the LPN was still off the unit at 10:42 AM. The resident was not assessed when the LPN returned, and the medication was not administered until 11:10 AM, 40 minutes after the initial complaint. The resident later reported pain rated 7 out of 10, and the DON acknowledged that a resident should not wait 40 minutes for pain medication.
Missed Antibiotic Doses Not Reported to Provider
Penalty
Summary
The facility failed to ensure that Resident ID #17 was free from significant medication errors when the resident missed 6 doses of a prescribed antibiotic. The resident was admitted in April 2026 with diagnoses including surgical aftercare and complication of surgical and medical care, and had a physician order dated 4/3/2026 for Cefadroxil 500 mg by mouth twice daily for 14 days. Review of the April 2026 MAR showed missed doses on 4/3 at 8:00 PM, 4/6 at 8:00 PM, 4/11 at 8:00 PM, 4/12 at 8:00 AM, 4/14 at 8:00 PM, and 4/17 at 8:00 AM. The record did not show that the provider was notified of the missed antibiotic doses. During interview, the RN acknowledged the 6 missed doses and stated they should have been reported to the provider. The Medical Director stated she was unaware of the missed doses and said she would have extended the antibiotic course if she had known. The DON also acknowledged the missed doses and stated she would expect the provider to be informed if a resident misses any dose of an antibiotic.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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