Harris Health Center Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in East Providence, Rhode Island.
- Location
- 833 Broadway, East Providence, Rhode Island 02914
- CMS Provider Number
- 415098
- Inspections on file
- 24
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Harris Health Center Llc during CMS and state inspections, most recent first.
Surveyors found that food service operations did not meet professional standards in the main kitchen and a kitchenette. An ice machine contained visible pink residue on an internal component, and a worktable used at times for food preparation held a cell phone and beverage cups. One freezer contained a resident-labeled frozen chicken breast with heavy ice accumulation and multiple expired cream products, and the same freezer had damaged door molding with black buildup and a flaking interior finish. In the kitchenette refrigerator, surveyors observed an unlabeled, undated cup with white liquid and a brown bag labeled only with a resident’s name that held multiple food items, including unidentifiable cubed food with a patchy white film, all lacking required labeling, dating, and discard information per facility policy.
The facility failed to follow its own policy requiring informed consent and documentation before initiating or changing psychotropic medications for three residents with dementia, Alzheimer’s disease, and schizoaffective disorder. Records showed multiple psychotropic drugs and dose changes, including Rexulti, Seroquel, Trazodone, Mirtazapine, and Memantine, without evidence that residents or their representatives were informed in advance of new medications or dosage increases, or that risks, benefits, side effects, and treatment alternatives were explained. Documentation also lacked evidence that nonpharmacological interventions were attempted before starting these psychotropic therapies, despite expectations stated by the physician and DON.
The facility failed to document required monitoring for effectiveness and side effects of psychotropic medications for several residents with conditions such as schizoaffective disorder, dementia, Alzheimer’s disease, major depressive disorder, and bipolar disorder. Although care plans and facility policy called for monitoring of mood/behavior, adverse effects, and medication effectiveness, clinical records for these residents did not contain such documentation despite multiple psychotropic prescriptions. In interviews, the physician stated that staff should continuously monitor behaviors and attempt nonpharmacological interventions before initiating psychotropic therapy, while an RN acknowledged there was no system for behavior documentation and the DON could not demonstrate that monitoring was completed as expected.
A resident with dementia and severe cognitive impairment, care-planned for sexually inappropriate behavior and to be seated away from the opposite gender, was instead seated between two residents of the opposite gender in a community room while two staff members were present. Another cognitively impaired resident with behavioral disturbances struck this resident in the eye and forehead, causing a laceration and a bleeding scratch. Staff interviews confirmed that the two residents were known not to get along and that the resident with sexually inappropriate behaviors was supposed to be kept away from the opposite gender, yet the DON and Administrator could not provide evidence that this care plan intervention was followed or that the resident was kept free from physical abuse.
A resident with a history including acute respiratory failure with hypoxia was readmitted to the facility and later had an unplanned discharge to an acute care hospital, with return to the facility anticipated. Facility policy, as outlined in a document titled “RESIDENT BED HOLD NOTICE,” requires that residents and/or their representatives be informed of the bed-hold policy whenever a resident is transferred for hospitalization. Record review showed no written notice of the bed-hold policy was provided to the resident at the time of transfer, and the Social Worker could not produce documentation that such written notification occurred. This failure to provide written notice of the bed-hold policy at the time of hospital transfer resulted in the cited deficiency.
A resident admitted with hypo-osmolality and hyponatremia had physician orders for thin liquids with no free water and a regular diet with a fluid restriction. Surveyors found that these fluid restriction orders, in place since admission, were not incorporated into a comprehensive, person-centered care plan with measurable objectives and timeframes. During interview, the DON acknowledged that she would have expected the fluid restriction order to be included in the resident’s comprehensive care plan.
The facility failed to involve a resident’s court‑appointed guardian in ongoing care planning despite the resident having severe cognitive impairment and the guardian being listed as the primary representative, with no evidence of invitations or attempts to include the guardian in multiple care conferences. In a separate issue, the facility did not follow an existing care plan for a resident with dementia and sexually inappropriate behaviors, as the resident was seated between residents of the opposite gender in the dining room and staff did not intervene, leading to a resident‑to‑resident altercation. Additionally, the care plan for the resident who struck another resident, who had dementia with mood and behavioral disturbance and psychosis, was not revised by the IDT to include interventions related to the abuse incident, contrary to facility policy and expectations stated by the DON.
Surveyors found that staff did not consistently follow physician orders or professional standards in several cases. A resident with dementia never had an ordered urine culture obtained, and there was no documentation that the provider was notified when staff were unable to collect the specimen. A resident with a suprapubic catheter, ordered for Enhanced Barrier Precautions, received personal care from a CNA who did not wear a gown despite posted EBP signage. Two residents experienced repeated missed or refused doses of ordered medications, including gabapentin, eye lubricants, and hydroxyzine, without evidence that a nurse or provider was notified or that the issues were addressed. Another resident on a fluid restriction for hyponatremia had orders that did not specify the allowed fluid amount, and the record showed that, although the MD was contacted about unclear limitations, the order was never clarified and staff could not state the specific restriction.
Surveyors found that medications on a first-floor CMT medication cart were not stored and labeled according to the facility’s MASP policy and manufacturer guidelines. Two Wixela inhalers and one fluticasone propionate inhaler were out of their foil pouches, with one Wixela lacking an open-date label and the others labeled with open dates that exceeded manufacturer-recommended discard timeframes. An opened bottle of house-stock Allergy Relief (fexofenadine 180 mg), used for a resident, was present without a visible expiration date. The CMT acknowledged the issues, and the DON could not provide evidence that medication storage and labeling complied with facility policy and professional standards.
A resident with a history of food in the respiratory tract and an MDS indicating a need for partial/moderate assistance with eating had a physician’s order for staff to assist with meals at all times on day and evening shifts. Surveyors observed the resident eating independently in a common area without staff assistance during midday meals, while the Treatment Administration Record showed the ordered meal assistance as completed for those shifts. An RN acknowledged documenting the order as completed even though he did not assist the resident, had delegated the task to NAs, and did not know whether any NA had actually provided meal assistance. The DON stated she expected staff to follow physician orders and document accurately.
Surveyors found that the facility did not conduct required antibiotic “time outs” for two residents receiving antibiotic therapy. One resident with pneumonia, acute respiratory disease, and dysphagia received topical mupirocin to a toe wound without any documented day 2–3 antibiotic review. Another resident with pneumonia, acute respiratory failure, epilepsy, and repeated falls received azithromycin and ceftriaxone, again with no evidence of a day 2–3 antibiotic review. The DON could not provide documentation of antibiotic time outs and reported being unfamiliar with the antibiotic timeout process.
The facility did not complete a compliant facility-wide assessment to determine needed resources for competent resident care during routine operations and emergencies. The documented Facility Assessment, last updated in late 2025, listed the Administrator, DON, Social Worker, Medical Director, and a resident as participants, but there was no evidence that input from a resident representative or family members was solicited or considered, as required. During a surveyor interview, the Administrator could not provide proof of such input and acknowledged he was unaware that including a resident representative or family member was required.
A resident with a history of bipolar disorder and epilepsy, assessed as having intact cognition and independent ambulation, exited the facility without following the LOA policy by accessing an unsecured key at the staff desk and unlocking a rear door. Staff failed to complete the LOA log and did not notice the resident's absence until notified by police, resulting in a failure to provide adequate supervision and prevent elopement.
A resident experienced significant weight fluctuations, but the facility failed to re-weigh or notify the physician, dietician, and DNS as required by policy. The resident, at nutritional risk due to dysphagia, showed weight changes of up to 19 pounds in a week without documented follow-up actions.
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential safety hazards for residents. Three residents with various medical conditions were observed using bed rails without documented entrapment assessments. The Director of Nursing could not provide evidence of completed assessments, indicating a lapse in the facility's maintenance program.
A resident with schizoaffective disorder experienced falls without a comprehensive care plan in place. Despite the facility's Fall Prevention Program requirements, no fall-related care plan was developed after the resident's falls. Staff interviews confirmed the lack of a care plan addressing the resident's fall risk.
The facility failed to conduct quarterly fall assessments for two residents as ordered and did not notify the physician of psychiatric recommendations for two residents. One resident with dementia and major depressive disorder did not have a fall assessment since December 2023, and another with polyarthritis and a history of falling missed a June 2024 assessment. Additionally, psychiatric recommendations for Quetiapine and melatonin were not communicated to the physician.
Surveyors found deficiencies in medication storage and labeling, including expired Fluzone vaccines and undated opened medications like Latanoprost Solution and inhalers. Staff acknowledged these issues, which were observed in the medication storage room and cart.
Food Storage, Labeling, and Equipment Sanitation Deficiencies in Dietary Areas
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards in the main kitchen, a kitchenette, and related equipment. During an initial kitchen tour, the interior of the ice machine contained a white component with small flecks of pink, wipeable matter that could be removed with a paper towel, and the cook acknowledged this residue. On the same tour, a worktable that is occasionally used as a food preparation area had a cell phone and two beverage cups lying on it, which the cook acknowledged should not have been there. In one of three freezers, surveyors found a large zip-lock style bag labeled with a resident’s name and dated “7/21” containing a frozen chicken breast with an accumulation of ice crystals, and seven unopened containers of Rich’s On Top Soft Whip Sweet Cream with an expiration date of 9/19/2025; the cook acknowledged the products were expired and that the chicken breast should have been discarded earlier. The same freezer had a door with rubber molding partially hanging off, with an accumulation of black matter and food particles behind the molding, and the interior white-coated finish was scored, discolored, and flaking off in various locations, which the cook also acknowledged. In the kitchenette refrigerator, surveyors observed an unlabeled and undated eight-ounce Styrofoam cup filled with a white liquid, which the cook acknowledged should have been labeled, dated, and discarded. They also found a brown bag labeled only with a resident’s name that contained three individually wrapped cheese sticks, an opened bag of pepperoni, an unlabeled and undated zip-lock style bag containing a pickle, and an unlabeled and undated plastic container with unidentifiable cubed red and white food items covered with a patchy white film. The brown bag lacked a room number, a received-on date, and a discard-by date, contrary to the facility’s policy on food brought in by visitors, which requires nursing staff to monitor such food for spoilage, contamination, and safety, and to label it with the resident’s name, room number, and date, and discard after 24 hours. The cook acknowledged the lack of labeling and dating and the presence of the patchy white film on the food items.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent and to provide required information to residents or their representatives before initiating or changing psychotropic medications, as required by facility policy. The policy states that all psychotropic medications require resident or representative consent, including awareness of the medication, side effects (including black box warnings when applicable), and risk/benefit information, and that consent must be obtained prior to administration. The policy also requires that residents or representatives be informed of any new medications or dosage increases and that progress notes show evidence of this notification, as well as that nonpharmacological interventions be attempted before obtaining an order for a psychotropic medication. For one resident with dementia and severe cognitive impairment, record review showed multiple psychotropic medications and dose increases, including Rexulti at various dosages, Trazodone, and Memantine. The clinical record lacked evidence that the resident’s representative was informed in advance of the addition of new psychotropic medications or dosage increases, and there was no documentation that the representative was informed of risks, benefits, side effects, or treatment alternatives. The record also did not show that nonpharmacological interventions were attempted prior to initiating these psychotropic therapies. In an interview, the resident’s primary representative stated they were unaware of the additions and dose increases and would have expected to be notified. For another resident with Alzheimer’s disease and severe cognitive impairment, the record showed prescriptions for Seroquel, Trazodone, and Mirtazapine, but there was no evidence that the resident’s representative was informed in advance of the addition of these psychotropic medications, nor that risks, benefits, side effects, or alternatives were discussed. Similarly, for a resident with schizoaffective disorder, the provider ordered Seroquel as needed for sleep, and the medication was administered on two occasions; however, the record did not show that the resident was informed in advance of this addition to the regimen or of associated risks, benefits, side effects, or alternatives, and there was no documentation of attempted nonpharmacological interventions prior to prescribing the PRN Seroquel. In interviews, the physician stated that staff are expected to attempt nonpharmacological interventions before drug therapy, and the DON stated that residents or representatives should be informed of risks, benefits, and side effects of psychotropic medications, but she was unable to provide evidence that such interventions or notifications occurred for the cited residents.
Failure to Monitor Psychotropic Medications for Effectiveness and Side Effects
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate monitoring for effectiveness and side effects of psychotropic medications for multiple residents. The facility’s own policy on Medication Administration Safety; Psychotropic Medications and New Medication Orders requires that nonpharmacological interventions be attempted before psychotropic medications are ordered, and that new medications be monitored for effectiveness and side effects, with systems in place for re-evaluation by the IDT and care plan interventions addressing monitoring. Despite this policy, record reviews for several residents on psychotropic medications did not contain evidence of such monitoring. One resident with schizoaffective disorder was prescribed lithium carbonate and olanzapine, with a care plan directing monitoring of medication effectiveness, side effects, mood, and behaviors, yet the clinical record lacked documentation of this monitoring. Another resident with dementia was prescribed memantine, Rexulti, Seroquel, and trazodone, and had a care plan focus identifying risk for adverse effects from daily psychotropic use with an intervention to monitor mood/behavior and report adverse effects or ineffectiveness, but the record similarly lacked evidence of monitoring for effectiveness and side effects. A third resident with Alzheimer’s disease was prescribed Seroquel, trazodone, mirtazapine, and olanzapine, with a care plan intervention to monitor for changes in mood/behavior and adverse effects, but again, no documentation of such monitoring was found in the record. Additional residents were affected in the same manner. One resident with major depressive disorder was prescribed buspirone and venlafaxine, with a care plan focus on risk for adverse effects from psychotropic medications and an intervention to monitor mood/behavior and report side effects or ineffectiveness, yet the record contained no evidence of monitoring. Another resident with bipolar disorder was prescribed clozapine, divalproex, mirtazapine, and sertraline, with a care plan intervention to monitor for adverse effects and report changes, but the record also lacked documentation of monitoring for effectiveness and side effects. In interviews, the physician stated an expectation that staff continuously monitor residents’ behavior and attempt nonpharmacological interventions before starting psychotropic drugs. An RN reported there was no system in place for documenting residents’ behaviors, and the DON stated she expected behavior monitoring for psychotropic effectiveness and side effects and orders for nonpharmacological interventions prior to drug therapy, but could not show evidence that such monitoring occurred for the cited residents.
Failure to Follow Care Plan Leads to Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse by not following an existing care plan intervention to keep the resident away from members of the opposite gender. One resident with dementia and severe cognitive impairment, documented by a BIMS score of 7/15, had a care plan focus area noting increased episodes of sexually inappropriate behavior toward other residents, with an intervention to seat the resident away from residents of the opposite gender in the dining room. On the date of the incident, this resident was seated in the community room between two residents of the opposite gender, including another resident with dementia, mood and behavioral disturbance, unspecified psychosis, and a BIMS score of 1/15. Surveillance video reviewed by surveyors showed that two staff members were present in the area and did not separate the resident from residents of the opposite gender as required by the care plan. An altercation occurred in which the second resident struck the care-planned resident in the eye and forehead, causing a small laceration to the left forehead and a bleeding scratch under the right eye. A facility incident report documented that the second resident struck the first resident with a fist after the first resident allegedly attempted to touch the second resident’s genital area. A nursing assistant later stated she had been told that the first resident attempted to touch the second resident’s groin, but also reported that after facility staff reviewed the surveillance video, it was determined that no such attempt occurred. A registered nurse reported that the two residents “don’t mix” and that staff try to keep them separated, and also confirmed that the resident with sexually inappropriate behaviors was to be kept away from residents of the opposite gender for a long time. The DNS and Administrator were unable to provide evidence that the care plan intervention to keep the resident away from residents of the opposite gender was followed, and the Administrator could not provide evidence that the resident was kept free from physical abuse.
Failure to Provide Written Bed-Hold Notice at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide a hospitalized resident with written notice of its bed-hold policy at the time of transfer. The facility’s undated document titled “RESIDENT BED HOLD NOTICE” states that whenever a resident is transferred for hospitalization, the resident and/or representative must be informed of the facility’s policy concerning holding the bed. Record review showed that the resident, who had been readmitted in November 2025 with diagnoses including acute respiratory failure with hypoxia, experienced an unplanned discharge and transfer to an acute care hospital on 1/3/2026, with an anticipated return to the facility. Further review of the clinical record did not reveal any evidence that written notice of the bed-hold policy was provided to the resident at the time of this transfer. In an interview on 1/30/2026, the Social Worker was unable to provide documentation that the resident had been notified in writing of the bed-hold policy when transferred on 1/3/2026. This lack of written notification at the time of hospital transfer for a resident expected to return constitutes the identified deficiency.
Failure to Incorporate Fluid Restriction Orders into Comprehensive Care Plan
Penalty
Summary
Surveyors identified that the facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident who had a physician’s order for fluid restriction. The resident was admitted in October 2025 with diagnoses including hypo-osmolality and hyponatremia, a condition characterized by excess body water relative to sodium. Record review showed dietary physician’s orders starting 10/14/2025 specifying thin liquids with no free water due to fluid restriction and a regular texture diet with a fluid restriction with meals. Further review of the clinical record did not reveal any evidence that these fluid restriction orders were incorporated into the resident’s comprehensive care plan. In an interview, the Director of Nursing Services stated she would have expected the physician’s order for the fluid restriction to be included in the resident’s comprehensive care plan. This deficiency was cited for 1 of 1 residents reviewed who had a physician’s order for a fluid restriction, as the facility did not ensure that the resident’s medical, nursing, and psychosocial needs related to fluid restriction were addressed through a comprehensive care plan.
Failure to Involve Guardian in Care Planning and to Revise Care Plans After Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s court‑appointed guardian was invited to and allowed to participate in the care planning process, and the failure to review and revise comprehensive care plans after a resident‑to‑resident abuse incident. One resident with Alzheimer’s disease, severely impaired cognition as evidenced by a Brief Interview for Mental Status score of 3/15, and a legally appointed guardian was readmitted in December 2024. Record review showed quarterly care conferences held on four dates in 2025, with documentation that the guardian participated in only the first conference. The guardian reported not being invited to any meetings to discuss the resident’s care for over a year, and the Social Worker was unable to provide evidence of attempts to notify or involve the guardian in the subsequent three care conferences, limiting the guardian’s ability to participate in development, review, and revision of the resident’s person‑centered care plans. The deficiency also includes the facility’s failure to follow its abuse prohibition policy requiring that staff interventions be carried out and included in the resident’s care plan, and to revise care plans after a resident‑to‑resident abuse incident. One resident with dementia had a care plan initiated in December 2024 for increased episodes of sexually inappropriate behavior toward other residents, with an intervention to seat the resident away from residents of the opposite gender in the dining room. Video footage from November 2025 showed this resident seated between two residents of the opposite gender, including the resident who later struck the resident, while two staff members present did not intervene to follow the seating intervention. Another resident, readmitted with dementia with mood and behavioral disturbance and unspecified psychosis, had a care plan problem indicating mood‑related resident‑to‑resident incidents, but record review did not show that the care plan was revised to include interventions specific to the November 2025 resident‑to‑resident abuse incident. The DNS stated she would have expected the care plan to be updated with new interventions.
Failure to Follow Physician Orders for Labs, Infection Control, Medications, and Fluid Restriction
Penalty
Summary
The deficiency involves multiple failures to follow physician orders and professional standards of quality for several residents. One resident with dementia had increased agitation and confusion, prompting the provider to order blood work and a urine specimen for culture and analysis. Progress notes documented that the resident refused to provide a urine sample on one date and that staff were unable to obtain the specimen on another date, but the record contained no evidence that the urine specimen was ever obtained or that the provider was notified of the inability to obtain it. The resident’s physician later stated he did not recall being informed and would have expected notification, and the DNS also stated she would have expected the specimen to be obtained as ordered or the provider to be notified with documentation. Another resident with neuromuscular bladder dysfunction and a suprapubic catheter had a care plan and physician order requiring Enhanced Barrier Precautions (EBP) every shift, including use of gown and gloves for high-contact care such as personal hygiene. EBP signage on the resident’s door instructed staff to wear a gown and gloves for activities like dressing, bathing, hygiene, and changing briefs. A surveyor observed a nursing assistant in the resident’s room adjusting bed linens while wearing only one glove and no gown, and the assistant reported she had just completed personal care without a gown despite acknowledging the EBP signage, stating she had been told a gown was not required. The Infection Preventionist stated she would have expected staff to wear a gown when assisting with the resident’s personal care. Additional deficiencies involved medication management and fluid restriction orders. One resident with stroke and seizures had physician orders for gabapentin and two eye medications, but the MAR showed frequent refusals of all three medications over many days, with no documentation that a provider was notified of these ongoing refusals. A medication technician stated the resident often refused medications and that she simply marked them as refused, without indicating that she notified a nurse or provider, while the DNS stated she would have expected such refusals to be communicated and documented. Another resident with dementia had an order for hydroxyzine pamoate three times daily, but the MAR showed multiple missed doses on several days without evidence that the provider was notified or that the doses were given, and the DNS could not provide evidence the medication was administered as ordered. A further resident admitted with hypo-osmolality and hyponatremia had dietary orders for thin liquids with no free water due to a fluid restriction and a regular diet with a fluid restriction, but the record did not specify the amount of fluid allowed. A progress note documented that the MD was contacted because information about the limitation was unclear and that it was due to low sodium, yet there was no evidence the order was clarified, and both a medication technician and the physician later confirmed that the specifics of the restriction were not defined in the order.
Improper Storage and Labeling of Medications on Medication Cart
Penalty
Summary
Surveyors identified a failure to store and label medications according to professional standards and the facility’s own Medication Administration Safety Program (MASP) policy on one of three medication carts reviewed. The policy requires periodic checks for expired medications, prohibits altering labels except to note the date opened, and mandates that inhalers be labeled and stored per manufacturer guidelines. During observation of the first-floor CMT medication cart with the CMT present, surveyors found a Wixela inhalation device out of its foil package with a dose counter of 57 that was not labeled with the date it was opened, and another Wixela device out of its foil pouch with a dose counter of 5 that was labeled as opened on 10/23/2025, despite manufacturer guidance that the device should be discarded one month after removal from the foil pouch or when the dose counter reaches zero. A fluticasone propionate inhalation device was also found out of its foil pouch with a dose counter of 45 and labeled as opened on 10/23/2025, even though manufacturer guidance states it should be discarded two months after opening the foil pouch or when the dose counter reaches zero. Additionally, surveyors observed one opened bottle of Allergy Relief (fexofenadine hydrochloride 180 mg) on the cart that lacked a visible expiration date. The CMT acknowledged these findings and stated that the Allergy Relief was house stock and that a resident was currently prescribed this medication. In a subsequent interview, the DON was unable to provide evidence that the facility stored and labeled drugs in accordance with the facility’s policy and accepted professional principles, confirming the deficiency in medication storage and labeling practices on the reviewed medication cart.
Inaccurate Documentation of Ordered Meal Assistance
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate medical records and to document care in accordance with professional standards for a resident with a physician’s order for assistance with meals at all times. The resident was readmitted in December 2021 with a diagnosis that included food in the respiratory tract causing injury. A Minimum Data Set assessment dated in January 2026 indicated the resident required partial/moderate assistance of one staff member for eating. A physician’s order dated 11/25/2025 directed staff to assist the resident with meals at all times, twice daily, during the 7:00 AM–3:00 PM and 3:00 PM–11:00 PM shifts. Surveyors observed the resident eating independently in a common area without staff assistance on two separate occasions during the midday meal period. Despite these observations, the January 2026 Treatment Administration Record showed the physician’s order for meal assistance as completed for the 7:00 AM–3:00 PM shift on both days. During an interview, the RN who documented completion for one of those shifts admitted he had not personally assisted the resident with eating, stated that the task was delegated to NAs, and acknowledged he did not know which NA, if any, had assisted the resident during lunch. He further acknowledged that he documented the order as completed despite being unaware whether the assistance had actually been provided. The DON stated she would expect staff to follow physician orders and document accurately in the resident’s record.
Failure to Conduct Required Antibiotic Time Outs for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement an Infection Prevention and Control Program that includes an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use, specifically the required antibiotic “time outs.” For one resident readmitted in June 2025 with diagnoses including pneumonia, acute respiratory disease, and dysphagia, physician orders directed the use of topical mupirocin 2% to the left great toe over two ordered time periods in January 2026. Record review did not show any evidence that an antibiotic time out or a review at day two or three was conducted for this mupirocin therapy. For another resident readmitted in June 2025 with diagnoses including pneumonia, acute respiratory failure, epilepsy, and repeated falls, physician orders included azithromycin 250 mg (two tablets once, then one tablet daily for four days) and ceftriaxone 1 gram daily over several days in December 2025. Additional record review failed to reveal documentation that an antibiotic time out or a day two or three review was completed for either the azithromycin or ceftriaxone. During an interview, the Director of Nursing Services was unable to provide evidence that antibiotic time outs or reviews had been completed and acknowledged being unfamiliar with the antibiotic timeout process.
Failure to Include Resident Representative and Family Input in Facility Assessment
Penalty
Summary
The facility failed to complete and document a compliant facility-wide assessment to determine the resources necessary to care for residents competently during routine operations and emergencies. Record review showed a document titled “Facility Assessment” last updated on 9/30/2025, which listed the Administrator, Director of Nursing Services, Social Worker, Medical Director, and a resident as participants in its completion. However, further review of this assessment did not show any evidence that the facility solicited or considered input from a resident representative or family members, as required by regulation. In an interview with surveyors, the Administrator was unable to provide evidence that such input had been included and stated that he was unaware that obtaining input from a resident representative or family member was a requirement. No additional resident-specific clinical information, medical history, or condition at the time of the deficiency was provided in the report.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Lax Key Security
Penalty
Summary
A deficiency occurred when a resident with a history of bipolar disorder and epilepsy, who was assessed as having intact cognition and ambulates independently, left the facility without following the leave of absence (LOA) policy. The resident had previously been identified as at risk for elopement, and the care plan included interventions such as ensuring staff awareness of the resident's wander risk and adherence to the LOA policy. Despite these interventions, the resident was able to access a key left in an accessible location at the staff desk, unlock a rear door, and exit the facility without staff knowledge. The resident traveled by bus to visit a relative at a hospital and later requested police assistance to return to the facility. Staff interviews and record reviews revealed that the LOA log was not completed as required, and the nurse on duty did not sign off on the resident's departure or return. Video surveillance confirmed the resident's actions in obtaining the key and exiting the facility. Staff acknowledged that the key remained accessible in the same location even after the incident, and the resident's unauthorized absence was only discovered when the police contacted the facility. These actions and inactions resulted in a failure to provide adequate supervision and prevent an elopement, as required by facility policy.
Failure to Monitor and Address Significant Weight Changes
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, as evidenced by significant weight fluctuations that were not addressed according to the facility's policy. The resident, who was at nutritional risk due to dysphagia and required a mechanical soft diet, experienced significant weight losses and gains over several weeks. Despite the facility's policy requiring re-weighing within 24 hours and notifying the physician, dietician, and Director of Nursing Services (DNS) of such changes, these actions were not documented or performed. The resident's weight records showed fluctuations of up to 19 pounds in a week, yet there was no evidence of re-weighing or notification to the relevant healthcare professionals. Interviews with the primary physician, DNS, and registered dietician confirmed that they were not informed of the significant weight changes, and the dietician had not assessed the resident since being hired. This lack of adherence to the facility's protocol resulted in a deficiency in maintaining the resident's nutritional status.
Failure to Conduct Regular Bed Safety Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential safety hazards for residents. Specifically, the surveyor identified that the facility did not perform entrapment assessments for three residents who were observed using bed rails. These residents included one with osteoarthritis and joint disorders, another with hemiplegia affecting the right side, and a third with spinal stenosis and a burst fracture of the T9-T10 vertebrae. The lack of documented entrapment assessments indicates a failure in the facility's maintenance program to ensure the safety of bed equipment. During the survey, observations were made over several days, noting the presence of side rails on the beds of the affected residents. Interviews with the Director of Nursing Services revealed that there was no evidence of completed entrapment assessments for these residents. This oversight suggests that the facility did not adhere to the guidelines outlined in the State Operations Manual Appendix PP, which requires routine preventive maintenance and safety checks to prevent resident entrapment.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who experienced falls. The resident, who was readmitted to the facility in December 2023 with a diagnosis of schizoaffective disorder, had documented falls on two occasions: July 9, 2024, and August 14, 2024. Despite these incidents, the facility did not create a fall-related care plan that identified preventative measures or interventions to address the resident's fall risk. The facility's Fall Prevention Program, last revised in December 2010, mandates that fall risk assessments be conducted during admission, quarterly reviews, and significant changes in condition. It also requires that a care plan be developed for residents with a history of falls or high fall risk scores. However, a review of the resident's records and interviews with staff, including a Registered Nurse and the Director of Nursing Services, confirmed the absence of such a care plan for the resident in question.
Failure to Conduct Fall Assessments and Notify Physician of Psychiatric Recommendations
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. Specifically, two residents with physician orders for quarterly fall assessments did not have these assessments completed as required. One resident, admitted in December 2011 with dementia and major depressive disorder, had a physician's order for quarterly fall assessments, but the last documented assessment was on December 26, 2023. Another resident, admitted in March 2024 with polyarthritis, fibromyalgia, muscle weakness, and a history of falling, also had a physician's order for quarterly fall assessments, but no assessment was completed in June 2024 as ordered. Additionally, the facility did not notify the physician of psychiatric recommendations for two residents. One resident, seen for agitation and behavioral disturbance, had a recommendation to restart Quetiapine, but there was no evidence that the physician was informed. Another resident, with schizophrenia and generalized anxiety disorder, had a recommendation for melatonin, but again, there was no evidence of physician notification. Interviews with the primary care physician and the psychiatric nurse practitioner confirmed these lapses, and the Director of Nursing Services acknowledged the deficiencies.
Deficiency in Medication Storage and Labeling
Penalty
Summary
The facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles. During a surveyor observation of the 1st floor medication storage room, it was found that a 10-dose box of Fluzone vaccine and a 10-dose box of High Dose Fluzone vaccine, both with 5 doses remaining, were expired. Staff A, a Registered Nurse, acknowledged the expired status of these vaccinations during an interview immediately following the observation. Additionally, during an observation of the 1st floor Certified Medication Technician medication cart, it was revealed that there were two bottles of Latanoprost Solution, an eye drop used to treat glaucoma, that were opened and undated, despite manufacturer instructions to discard them 6 weeks after opening. Furthermore, a Wixela inhaler and two Trelegy Ellipta inhalers, used to treat asthma, were also found opened and undated, contrary to manufacturer instructions to discard them after specific periods once opened. Staff A acknowledged these medications were opened and undated, and the Director of Nursing Services confirmed the expectation for staff to date medications when opened and discard them appropriately.
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The facility failed to follow physician orders for post-fall care for three anticoagulated residents who experienced falls. One resident on a blood thinner with a head injury was ordered to be transferred to the ED after a telehealth evaluation, but an LPN did not send the resident, citing instructions to contact a supervisor first and inability to reach that supervisor. For two other residents on anticoagulants, providers ordered intensive neuro checks (every 15 minutes, then every 30 minutes, then hourly, then every 4 hours), but staff instead performed neuro checks only once per shift for 72 hours. The DON and Medical Director acknowledged that the transfer and monitoring orders were not implemented as written.
A resident with intact cognition and psychiatric diagnoses sustained a left eyebrow laceration when another resident with a documented history of escalating aggressive and threatening behaviors struck them with a cane during a hallway dispute. The aggressive resident had multiple prior documented incidents, including verbal threats to kill others, attacking a roommate with a cane over TV volume, throwing objects during activities, and throwing a lunch plate at staff. Despite these events, the care plan was not updated with interventions to address physical aggression toward other residents, and a psychiatric recommendation for PRN trazodone for agitation, anxiety, and insomnia was only implemented as PRN for insomnia. The failure to assess, monitor, and implement effective interventions for the aggressive resident’s behaviors led to the assault and injury and, per the report, placed this and other residents at risk of serious physical and psychosocial harm.
A resident with impulse disorder, mood and anxiety diagnoses, and a history of escalating verbal and physical aggression had multiple documented incidents of threats, object throwing, and assault with a cane. Despite a psychiatric consult recommending PRN trazodone for agitation, anxiety, and insomnia, the provider order listed insomnia only, and the care plan was not updated with specific interventions to address the resident’s physically aggressive behaviors after several documented events. Subsequently, the resident struck another resident with a cane, causing a facial laceration that required wound closure and ongoing treatment.
The facility failed to properly screen and document clearance for a NA with disqualifying criminal history information before hire, as required by its abuse, neglect, and exploitation policy. A BCI check showed disqualifying information, yet the NA was hired, completed orientation, and worked independently based only on verbal disclosure of an old drug-related charge, without written details or verification. Later, a staff member reported witnessing this NA grab a resident’s face and kiss the resident on the lips, and a community complaint alleged inappropriate interactions with the same resident, prompting involvement of local police.
A resident with anxiety disorder and PTSD was unable to attend meals and activities with peers because the facility lost the resident's clothing after it was sent to laundry. The resident was observed in a hospital gown with only a few clothing items in the room, and the record lacked an admission inventory of belongings. The DON/Administrator reported that laundry was handled by an outside vendor without a tracking system or item documentation.
A resident with dementia and severely impaired cognition was subjected to repeated non-consensual kissing on the lips by an NA, who entered the resident’s room during care, verbally expressed affection, and then kissed the resident on the mouth on at least two separate occasions witnessed by staff. One staff member delayed reporting the first incident due to fear of the NA. These actions occurred despite a facility policy defining sexual abuse as any non-consensual sexual act and requiring protections of residents’ rights and well-being.
Failure to investigate allegations of resident-to-resident sexual inappropriateness: A resident with dementia and TBI was documented as being inappropriate with another resident, and psych notes later described increased sexually inappropriate behaviors toward other residents. Staff interviews showed the resident had been observed touching others and needing frequent redirection, but the DON, ADON, and Administrator acknowledged the facility did not complete an investigation or recognize the allegation as possible abuse.
A resident with dementia and a hearing deficit did not receive ear care as ordered because the chart lacked the Debrox order and the ear was flushed before the intended Debrox course was completed. In a separate incident, staff witnessed inappropriate kissing of a resident with dementia, but the allegation was not reported to the provider and the care plan was not updated. A third resident’s wound care was also not completed as ordered when an RN used normal saline instead of the prescribed Vashe wound wash.
A resident with migraines and chronic pain did not receive timely pain management after repeatedly reporting a migraine and appearing in visible distress. An NA notified an LPN, an RN said she could not access the med cart, and the resident continued waiting while the LPN was off the unit; the PRN migraine medication was not given until 40 minutes after the first complaint. The DON acknowledged the resident should not have waited that long for pain medication.
A resident missed 6 doses of a prescribed antibiotic, and the MAR did not show that the provider was notified. The RN acknowledged the missed doses and said they should have been reported, while the Medical Director stated she was unaware of the missed doses and would have extended the antibiotic course if informed. The DON also confirmed the missed doses and expected provider notification for any missed antibiotic dose.
Failure to Follow Post-Fall Physician Orders for Anticoagulated Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement physician orders for post-fall care, including hospital transfer and neurological monitoring, for residents on anticoagulant therapy. One resident with atrial fibrillation on Xarelto experienced an unwitnessed fall with a scalp laceration and head lump. The on-call provider, after a telehealth evaluation, ordered transfer to the ED and wrote an order directing that the resident be sent to the hospital. The resident was not transferred as ordered, and an additional order for vital signs and neuro checks every shift for 72 hours after the fall was not completed as ordered on one of the shifts. The LPN caring for this resident stated she did not send the resident to the ED because she had been instructed to call a supervisor before sending residents out, and she was unable to reach the supervisor during the shift. A second resident, also with atrial fibrillation and on Xarelto, had an unwitnessed fall with injury. The on-call provider was notified and ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, then every four hours for an additional 24 hours. A physician’s order reflecting this schedule was scanned into the EMR. However, the neuro checks were not completed as ordered; instead, they were performed only once per shift for 72 hours. The RN who authored the progress note documented the fall and the resident’s anticoagulant use, and later stated she could not remember why she did not transcribe and complete the neuro checks as ordered. A third resident with atrial fibrillation on Apixaban had a non-injury fall after attempting to walk independently. The on-call provider ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, and then every four hours for an additional 24 hours, and this order was scanned into the EMR. The record did not show that these neuro checks were completed as ordered; instead, neuro checks were documented only once per shift for 72 hours. The Medical Director stated he would have expected the first resident to be transferred to the ED as ordered and that the facility should not override a provider’s order. The DON acknowledged that the transfer order and the ordered monitoring for the first resident were not followed as written, and that for the second and third residents, staff performed only once-per-shift neuro checks instead of the more frequent monitoring ordered by the providers.
Failure to Manage Escalating Aggression Leading to Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident, Resident ID #1, from abuse by another resident with a known history of escalating aggression, Resident ID #2. Resident ID #1 was admitted in October 2025 with diagnoses including paranoid schizophrenia and adjustment disorder with mixed anxiety and depressed mood, and had a BIMS score of 14/15, indicating intact cognition. On 4/27/2026, progress notes documented that Resident ID #1 was on the receiving end of a physical altercation with another resident and was found with a deep bleeding abrasion to the left eyebrow. A subsequent nursing note described a new laceration to the left eyebrow measuring 0.5 cm by 2.0 cm by 0.1 cm, related to a resident-to-resident incident, for which wound closure strips were applied. Resident ID #1 requested police involvement and a police report, and refused transfer to the hospital for sutures. Resident ID #2 had been admitted in December 2024 with multiple psychiatric and behavioral diagnoses, including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed a BIMS score of 13/15 and documented both physical and verbal behaviors during the look-back period. Progress notes over several months recorded a pattern of escalating aggressive and threatening behaviors: on 9/13/2025, Resident ID #2 threatened to slit another resident’s throat and made additional threats toward staff; on 11/7/2025, the resident was involved in a verbal dispute with raised voice, name-calling, and verbal threats; on 12/28/2025, after another resident struck Resident ID #2 with a helmet, Resident ID #2 was overheard threatening to kill that resident if touched again. On 2/21/2026, the on-call provider documented that Resident ID #2 attacked a roommate with a cane over TV volume and required ER transfer for psychiatric evaluation. Subsequent notes on 3/9/2026 and 4/10/2026 described the resident throwing poker chips on the floor, yelling and swearing at staff and residents, and throwing a lunch plate across the nurses’ station at a nursing assistant due to dissatisfaction with portion size. Despite this documented pattern, the care plan for Resident ID #2, dated 1/16/2025, only indicated a behavior problem of being verbally aggressive toward staff with resident-to-resident altercations on 12/28/2025, 2/21/2026, and 4/27/2026, and record review failed to show added interventions to mitigate the risk of physical aggression toward other residents after the 2/21/2026 cane attack and the object-throwing incidents on 3/9/2026 and 4/10/2026. A psychiatric evaluation on 4/23/2026 recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order entered on 4/24/2026 specified trazodone 25 mg twice daily as needed only for insomnia, and record review did not show that agitation and anxiety were included as indications for use. During interviews, the RNP and the DON stated it was their expectation that agitation and anxiety would have been included in the trazodone order, and the DON was unable to provide evidence that the care plan had been updated with interventions to address Resident ID #2’s physically aggressive behaviors documented on 2/21/2026, 3/9/2026, and 4/10/2026. On 4/27/2026, the DON documented that Resident ID #2 was ambulating down the hall toward his/her room while Resident ID #1 was walking in the opposite direction, and the two residents began a verbal dispute. Before staff could intervene, Resident ID #2 used his/her cane to make contact with Resident ID #1, resulting in the eyebrow laceration that required steri-strips and ongoing wound treatment. A police incident report recorded that Resident ID #1 stated being struck with a walking cane, wanted to press charges, and that Resident ID #2 admitted to striking Resident ID #1, leading to an arrest on one count of felony assault with a dangerous weapon. The facility’s failure to assess, monitor, and implement effective interventions for Resident ID #2’s known and escalating aggressive behaviors, including failure to update the care plan after prior incidents and failure to fully implement psychiatric recommendations, resulted in this resident-to-resident altercation and injury, and the report states that this failure placed Resident ID #1 and other residents at risk of serious physical and psychosocial harm.
Failure to Implement Psychiatric Recommendations and Update Behavior Care Plan Leading to Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health services and care planning for a resident with a documented history of psychiatric conditions and aggressive behaviors. The resident was admitted in December 2024 with diagnoses including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed intact cognition with a BIMS score of 13/15 and documented physical and verbal behaviors during the look-back period. Over time, multiple behavioral incidents were recorded, including threats to slit another resident’s throat during a smoking session, verbal disputes with name-calling and threats, and a statement to another resident that if touched again the resident would be killed. Further documentation showed escalating behaviors, including an incident where the resident attacked a roommate with a cane over television volume and required ER transfer for psychiatric evaluation, throwing poker chips and yelling when not winning at Bingo, causing the roommate to avoid the shared bathroom due to inappropriate comments and frustration over the light being turned on at night, and throwing a lunch plate across the nurses’ station at a nursing assistant over portion size. The care plan, initiated in January 2025 for verbal aggression and resident-to-resident altercations, did not contain added interventions to address the resident’s physically aggressive behaviors toward others after the incidents on 2/21/2026, 3/9/2026, and 4/10/2026. The DNS later could not provide evidence that the care plan had been updated with interventions to mitigate the risk of these physically aggressive behaviors or to guide staff in ensuring the safety of other residents. On 4/23/2026, a psychiatric evaluation recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order dated 4/24/2026 implemented trazodone 25 mg twice daily as needed for insomnia only, and the record lacked evidence that agitation and anxiety were included as indications for use as recommended by the consulting psychiatrist. Both the RNP and the DNS stated it was their expectation that the trazodone order would have included agitation and anxiety. Following this incomplete implementation of the psychiatric recommendation and the lack of updated behavioral interventions in the care plan, a resident-to-resident altercation occurred on 4/27/2026 in which the resident struck another resident with a cane, causing a laceration to the left eyebrow that required closure with steri-strips and ongoing wound treatment.
Failure to Properly Screen and Clear NA with Disqualifying Criminal History
Penalty
Summary
The facility failed to ensure that a prospective employee was properly screened and cleared for a history of abuse, neglect, exploitation, or misappropriation of resident property before hire. A nursing assistant, identified as Staff A, was hired on 11/18/2025 and was working independently as a NA. Prior to hire, a Bureau of Criminal Identification (BCI) check dated 11/6/2025 showed that Staff A had disqualifying information under federal and state law. Surveyor review after discovery of the positive BCI revealed that Staff A had an extensive criminal history. Despite this, the facility proceeded with the hire and allowed Staff A to complete orientation and work independently without obtaining or maintaining documentation specifying the nature of the disqualifying information, contrary to the facility’s Abuse, Neglect and Exploitation Policy, which requires screening and documentation of proof that such screening occurred. Subsequently, a facility-reported incident submitted on 4/17/2026 documented that a staff member reported witnessing Staff A grab a resident’s face and kiss the resident on the lips. A community-reported complaint submitted on 4/22/2026 alleged inappropriate interactions between the same NA and the same resident, and included a local police incident report indicating the resident’s family intended to pursue charges related to the incident. During interviews, the Human Resource Director stated that Staff A had disclosed disqualifying information related to a prior drug-related charge from about ten years earlier, but acknowledged there was no documentation specifying the nature of the disqualifying information and that this was known only by word of mouth. The Administrator stated she was aware that the BCI contained disqualifying information and that she exercised her own judgment in proceeding with the hire, and further acknowledged she did not receive documentation detailing the disqualifying information until it was brought to her attention by the surveyor.
Failure to Maintain Resident Clothing and Dignity
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity when the resident was unable to attend meals and activities with other residents because of a lack of appropriate clothing. The resident was admitted in May 2025 with diagnoses including anxiety disorder and post-traumatic stress disorder, and a care plan revised on 8/25/2025 described the resident as highly social and willing to participate in a variety of activities, with an intervention to provide reminders of scheduled events. During observation on 4/29/2026, the resident was found in the room wearing a hospital gown while other residents were in the dining room for lunch. Only one pair of pants and two T-shirts were observed in the room. The resident stated that the facility lost all of the resident's clothing, including shirts, pants, shorts, and socks, after they were sent to laundry services several months earlier and were never returned. The resident reported that the Administrator was told about the missing clothing, but no follow-up occurred and the clothing was neither located nor replaced. The record did not contain an admission inventory list of the resident's belongings, and the Administrator stated that laundry was handled by an outsourced company without a tracking system or documentation identifying which items belonged to which resident.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse when a nursing assistant (NA) was observed kissing the resident on the lips on more than one occasion. The resident, identified as having dementia and a Brief Interview for Mental Status (BIMS) score of 0/15 indicating severely impaired cognition, had been admitted in March 2026. On one occasion, a Certified Medication Technician (CMT) reported that while she was assisting the resident with breakfast, the NA entered the room, verbally expressed affection for the resident, made a kissing noise, leaned forward, and kissed the resident on the lips. This incident made the CMT uncomfortable, and she later discussed it with another NA. A separate staff member, another NA, reported that two days earlier she had observed the same NA enter the resident’s room while morning care was being provided, ask the resident if they remembered her, state that she loved the resident, then lean toward the resident, make a kissing sound, and kiss the resident on the mouth with full lip-to-lip contact. This second NA did not report the incident at the time because she was fearful of the NA involved and only came forward after learning of the later incident. The facility’s abuse, neglect, and exploitation policy defined sexual abuse as a non-consensual sexual act of any type with a resident and required protections for each resident’s health, welfare, and rights, as well as screening of potential employees for a history of abuse. Despite this policy, the resident with severely impaired cognition was subjected to repeated non-consensual kissing by the NA.
Failure to Investigate Allegations of Resident-to-Resident Sexual Inappropriateness
Penalty
Summary
The facility failed to ensure that allegations made by residents were recognized as possible abuse by staff and that all allegations were investigated for Resident ID #41, who was admitted with diagnoses including dementia and traumatic brain injury. A facility policy titled, Abuse, Neglect and Exploitation, stated that an immediate investigation is warranted when suspicion of abuse, neglect, exploitation, or reports of abuse, neglect, or exploitation occur. A progress note written by an RN documented that a resident reported Resident ID #41 was being inappropriate with another resident. Subsequent records included psychiatric evaluations stating the resident was being seen due to increased sexually inappropriate behaviors toward other residents and that sexual impulses may present an unsafe environment for other patients in the facility. Staff interviews revealed that Resident ID #41 had been observed touching other residents' shoulders and hands and required frequent redirection. The RN who documented the incident stated the behavior involved an attempted hug without contact and that both residents were separated and assessed, while the ADON and DON acknowledged they were unaware of the behavior or that the facility had not investigated the allegations. The Administrator also acknowledged that an investigation had not been completed to determine what sexually inappropriate behavior had occurred and that staff did not identify the allegation as possible abuse or investigate it immediately.
Failure to Follow Orders, Report Abuse, and Perform Ordered Wound Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for a resident with dementia and anxiety disorder who had a hearing deficit and complained of right ear wax buildup. The medical record showed an order for Debrox ear drops and a separate order to flush the right ear with warm water two times a day following Debrox usage for 5 days, but the record did not include a physician order for the Debrox solution. The April 2026 MAR showed the resident’s right ear was flushed six times, and the resident stated that the right ear still felt blocked. The RN acknowledged flushing the ear and was unaware whether Debrox had been given, while the DON stated the order had been entered incorrectly and that the ear should not have been flushed before Debrox administration. The NP stated the intended order was for Debrox twice daily for five days before irrigation and that she would not have ordered daily ear flushing. The facility also failed to report an allegation of abuse and failed to update the care plan for a resident with dementia after staff reported inappropriate interactions with a nursing assistant. A community complaint and police incident report indicated the family wanted to press charges, and the Administrator and DON confirmed that staff had reported witnessing the nursing assistant kiss the resident on two occasions. The record did not show that the allegation was reported to the provider, and the comprehensive care plan was not updated to reflect the allegation or any interventions related to the incident. The NP stated she was unaware of the incident and would have expected to be notified, and the ADNS acknowledged that the provider had not been notified and the care plan had not been updated. The facility further failed to follow a wound care order for a resident readmitted with peripheral vascular disease and cellulitis of the lower limb. The physician ordered cleansing open areas on the left lower leg with Vashe wound wash, applying xeroform to the wound bed, and wrapping with kling. During observation, the RN performing wound care did not use Vashe wash and instead cleansed the wound with normal saline. The RN acknowledged using normal saline rather than the ordered cleanser, and the DON stated she would expect the nurse to follow the wound orders as written.
Delayed Pain Medication for Resident with Migraine
Penalty
Summary
Safe, appropriate pain management was not provided for Resident ID #17, who was admitted with diagnoses including migraines and chronic pain. The resident’s care plan dated 4/20/2026 included a goal for the resident to verbalize adequate pain relief and an intervention to respond immediately to any complaint of pain. The physician ordered Butalbital-APAP-Caffeine 50-300-40 mg, 1 capsule every 12 hours as needed for migraine pain. On 4/29/2026 at 10:30 AM, the resident was observed in the hallway complaining of a migraine, moaning in pain, and holding his/her head. At 10:34 AM, an NA reported to an LPN that the resident wanted pain medication, and at 10:37 AM the resident continued to complain of migraine pain and told an RN about the pain, but the RN stated she did not have keys to the medication cart and could not get any pain medication. The resident continued to complain of severe head pain, returned to the room to lie down at 10:40 AM, and the LPN was still off the unit at 10:42 AM. The resident was not assessed when the LPN returned, and the medication was not administered until 11:10 AM, 40 minutes after the initial complaint. The resident later reported pain rated 7 out of 10, and the DON acknowledged that a resident should not wait 40 minutes for pain medication.
Missed Antibiotic Doses Not Reported to Provider
Penalty
Summary
The facility failed to ensure that Resident ID #17 was free from significant medication errors when the resident missed 6 doses of a prescribed antibiotic. The resident was admitted in April 2026 with diagnoses including surgical aftercare and complication of surgical and medical care, and had a physician order dated 4/3/2026 for Cefadroxil 500 mg by mouth twice daily for 14 days. Review of the April 2026 MAR showed missed doses on 4/3 at 8:00 PM, 4/6 at 8:00 PM, 4/11 at 8:00 PM, 4/12 at 8:00 AM, 4/14 at 8:00 PM, and 4/17 at 8:00 AM. The record did not show that the provider was notified of the missed antibiotic doses. During interview, the RN acknowledged the 6 missed doses and stated they should have been reported to the provider. The Medical Director stated she was unaware of the missed doses and said she would have extended the antibiotic course if she had known. The DON also acknowledged the missed doses and stated she would expect the provider to be informed if a resident misses any dose of an antibiotic.
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