Hattie Ide Chaffee Home
Inspection history, citations, penalties and survey trends for this long-term care facility in East Providence, Rhode Island.
- Location
- 200 Wampanoag Trail, East Providence, Rhode Island 02915
- CMS Provider Number
- 415002
- Inspections on file
- 24
- Latest survey
- June 20, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Hattie Ide Chaffee Home during CMS and state inspections, most recent first.
Surveyors identified several deficiencies in food service safety and sanitation, including improper labeling of chemicals, lack of cleaning schedules for kitchen equipment, dietary staff not using required hair restraints, reuse of single-use containers, use of non-durable food contact surfaces, missing thaw dates on nutritional shakes, and absence of an irreversible thermometer to verify dish machine sanitization temperatures.
Two residents did not receive care in accordance with physician's orders and professional standards. One resident with chronic venous insufficiency and leg edema was observed with heels resting on a pillow instead of being offloaded as ordered. Another resident with cellulitis received a wound dressing (hydrofera blue) not prescribed by the physician, as confirmed by nursing documentation and staff interviews.
A resident with an indwelling urinary catheter was observed multiple times with the drainage bag not positioned below the bladder, contrary to the care plan and standard nursing procedures. Staff confirmed the improper placement, and the DON acknowledged the expectation for correct positioning was not met.
Surveyors observed multiple breaches in infection control practices, including a nurse failing to perform hand hygiene between glove changes during a wound dressing change, and staff entering rooms of residents on droplet and contact precautions without required PPE such as N95 masks, gowns, and gloves. Staff acknowledged these lapses, and leadership could not provide evidence that infection control protocols were consistently followed.
The facility did not ensure that several staff members, including administrative, clinical, and therapy personnel, received mandatory annual and onboarding training in key areas such as abuse prevention, infection control, dementia care, trauma-informed care, QAPI, and HIPAA, as required by the facility's assessment. This deficiency was confirmed through record review and staff interview, with no evidence provided to show completion of the required education.
A resident with severe cognitive impairment was prescribed Trazodone for hallucinations without notifying their Power of Attorney, contrary to facility policy. The resident's representative was not informed of the medication change, despite the facility's requirement to notify them of any changes in treatment. The DNS acknowledged the oversight during interviews.
A resident with a history of stroke and dysphagia was served a breakfast tray despite having an NPO order, leading to a choking incident. Staff interviews revealed a lack of awareness about the resident's dietary restrictions, resulting in the deficiency.
Two residents requiring supervision while eating were left unsupervised, with one consuming unthickened liquids against orders and the other struggling with improperly prepared meals. Staff were unaware of the supervision and dietary requirements, and care plans did not reflect these needs, placing residents at risk for harm.
The facility did not complete annual performance evaluations for its nursing assistants, as required. A review of personnel files showed that no evaluations were conducted within the last 12 months for five nursing assistants. The DON confirmed the absence of these evaluations during an interview.
The facility failed to store and distribute food according to professional standards, with surveyors finding unlabeled and expired items in the kitchen and kitchenette. Additionally, the facility lacked a required 3-bay sink for sanitizing equipment. The Food Service Director acknowledged these deficiencies.
The facility failed to maintain an effective infection prevention and control program, with deficiencies in water management, hand hygiene, and linen handling. Legionella bacteria levels were above acceptable limits, and the facility lacked a water flow assessment. Staff did not follow proper hand hygiene for a resident with C. diff, using hand sanitizer instead of soap and water. Additionally, soiled linen was improperly handled and stored, posing an infection risk.
The facility failed to notify physicians about unavailable medications for two residents and did not follow a physician's order for medication parameters for another resident with hypertension. This resulted in missed doses of Saccharomyces boulardii and improper administration of metoprolol tartrate without checking required blood pressure and heart rate parameters.
Surveyors found deficiencies in medication storage and labeling, including pre-poured medications labeled with room numbers, expired multivitamins, and improperly stored Latanoprost eye drops. In the medication storage rooms, expired Tuberculin and undated Lorazepam were found. Staff acknowledged these practices, and the DON confirmed that pre-pouring is not allowed and medications should be dated and discarded when expired.
A resident with major depressive disorder did not receive recommended Trazodone for anxiety due to a lack of communication with a physician. Despite documented recommendations and increased anxiety symptoms, staff interviews revealed no evidence of physician notification or order implementation.
A resident with dysphagia and pneumonitis was not provided with the required 1:1 feeding assistance, despite a physician's order. The resident was observed eating without supervision, and the physician admitted to not reviewing the order individually before signing. The DON expected physicians to review orders individually.
Two residents in the facility did not receive meals prepared according to their dietary needs. A resident with severe cognitive impairment and physical limitations was served whole and hard food items instead of soft, bite-sized pieces. Another resident, requiring nectar thick liquids and a pureed diet due to dysphagia, was given unthickened beverages. Staff interviews revealed a lack of adherence to dietary orders, with the DON unable to provide evidence of compliance.
Multiple Food Service Safety and Sanitation Deficiencies Identified
Penalty
Summary
Surveyor observations, record reviews, and staff interviews revealed multiple deficiencies in food storage, preparation, distribution, and service within the facility's main kitchen and two kitchenettes. Chemical containers were not properly labeled according to OSHA standards, as evidenced by a spray bottle marked only with handwritten text. The kitchen hood and screens had visible grease accumulation, and there was no documented cleaning schedule. Dietary staff were observed not wearing appropriate hair restraints or beard coverings, and the Food Service Director (FSD) could not provide evidence of compliance with these requirements. Additionally, breadcrumbs were stored in a single-use container that was being reused, and the FSD could not confirm its appropriateness for reuse. Equipment and utensils, such as a wooden butcher block and scratched lip plates, were not made of durable, nonabsorbent materials as required. Further deficiencies included the improper labeling of thawed nutritional shakes, as none of the observed products in the kitchenettes had use-by dates to indicate when they were thawed, contrary to manufacturer instructions. The FSD acknowledged this lapse. The facility also lacked an irreversible thermometer to verify that dish machine cycles reached the required sanitizing temperature, as required by the Rhode Island Food Code. These findings collectively demonstrate a failure to adhere to professional standards for food service safety and sanitation.
Failure to Follow Physician's Orders and Professional Standards of Practice
Penalty
Summary
The facility failed to ensure that residents received care in accordance with professional standards of practice and physician's orders for two residents. One resident, admitted with chronic peripheral venous insufficiency and bilateral lower extremity edema, had a physician's order to offload heels when in bed every shift. However, during multiple surveyor observations, the resident was found in bed with heels resting directly on a pillow, rather than being properly offloaded as ordered. The Director of Nursing Services confirmed that the observed positioning did not meet the physician's order. Another resident, admitted with cellulitis of the right lower extremity, had a physician's order for wound care specifying cleansing with Vashe, application of Santyl, and covering with gauze and kerlix wrap once daily. Nursing documentation and direct observation revealed that hydrofera blue, a wound dressing, was applied to the wound without a corresponding physician's order. Staff interviews confirmed the absence of an order for hydrofera blue, and the DNS acknowledged that staff are expected to review and follow physician's orders prior to performing dressing changes.
Failure to Position Catheter Drainage Bag Below Bladder
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was not provided appropriate catheter care as required by facility policy and standard nursing procedures. The resident, who had diagnoses including hemiplegia, hemiparesis, and urinary retention, had a physician's order for an indwelling catheter and a care plan specifying that the drainage bag should be positioned below the level of the bladder. Multiple surveyor observations found that the drainage bag was not visible while the resident was in bed, and upon further inspection, it was discovered that the bag was attached to the resident's leg and lying perpendicular, not below the bladder as required. Staff interviews confirmed that the drainage bag was not positioned according to the care plan and standard procedures. Both a nursing assistant and a registered nurse acknowledged that the bag was not below the bladder, and the Director of Nursing Services stated that her expectation was for the drainage bag to be placed below the bladder. These findings demonstrate that the facility failed to provide appropriate catheter care for the resident, as required by both the care plan and established nursing guidelines.
Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by multiple observed breaches in infection control practices. During a wound dressing change for a resident with functional urinary incontinence and a coccyx wound, a registered nurse did not perform hand hygiene between glove changes as required by facility policy. The nurse removed soiled gloves, failed to wash hands or use hand sanitizer, and then donned new gloves before continuing the dressing change process. The nurse acknowledged during interview that proper hand hygiene was not performed at each glove change. Additional deficiencies were observed regarding the implementation of droplet and contact precautions for residents with communicable diseases. One resident on enhanced droplet/contact precautions had signage indicating that staff should wear an N95 mask before entering the room. However, a certified medication technician entered the room without the required N95 mask and confirmed this lapse during interview. Another resident with C. diff was on contact precautions, with signage instructing staff to wear a gown and gloves. Both a dietary aide and a nursing assistant entered the resident's room without wearing the required personal protective equipment, and both acknowledged the failure to follow protocol during interviews. Interviews with the infection control preventionist and the director of nursing services confirmed that staff were expected to follow the posted infection control precautions, but there was no evidence provided that these precautions were consistently followed. The observed failures to adhere to established infection control policies and procedures contributed to the deficiency cited during the survey.
Failure to Provide Required Staff Training
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for both new and existing staff members, as evidenced by the lack of required annual and onboarding education for seven employees. Record reviews showed that staff members in various roles, including administration, certified medication technician, nursing assistants, registered nurse, and occupational therapist, did not have documentation of completed mandatory training in areas such as abuse and neglect, infection control, dementia and behavioral health management, trauma-informed care, QAPI, corporate compliance, fire safety/disaster procedures, HIPAA, and resident rights for the year 2024. The facility assessment, last updated in January 2025, outlined the necessity for such training to ensure person-centered care, but the records did not support compliance with these requirements. During an interview, the staff developer was unable to provide evidence that the identified staff members had received all required mandatory training for 2024. The deficiency was identified through both record review and staff interview, confirming that the facility did not ensure all employees received the necessary education consistent with their roles and the facility's assessment of resident needs.
Failure to Notify Resident's Representative of Medication Change
Penalty
Summary
The facility failed to inform a resident's representative about a new medication order and the resident's hallucinations, which is a violation of their policy to notify residents and their representatives of changes in medical condition or treatment. The resident, who was admitted in May 2024 with severe cognitive impairment and a history of encephalopathy and stroke, was prescribed Trazodone by a Nurse Practitioner after experiencing hallucinations. However, there was no documentation that the resident's Power of Attorney was informed about this new medication or the hallucinations. The facility's policy requires that the resident, attending physician, and the resident's representative be promptly notified of any changes in the resident's condition or treatment plan. Despite this, the Medication Administration Records showed that Trazodone was administered multiple times without the representative's knowledge. During interviews, the complainant, who is the resident's Power of Attorney, confirmed they were not consulted about the medication change and expressed concerns about the resident's sensitivity to medications. The Director of Nursing Services acknowledged the lack of notification and documentation regarding the new medication order.
Failure to Follow NPO Order Results in Resident Choking Incident
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice by not adhering to a physician's order for a resident who was designated as nothing by mouth (NPO). The resident, who had a history of cerebral infarction, flaccid hemiparesis, dysarthria, and dysphagia, was admitted with a gastrostomy tube feeding order. Despite the NPO order, the resident was served a breakfast tray and consumed some of the food, which led to a choking incident observed by a family member. Interviews with staff revealed a lack of awareness regarding the resident's NPO status. Nursing assistants acknowledged the presence of a breakfast tray at the resident's bedside, and the Assistant Director of Nursing confirmed the incident, noting that the tray was removed upon discovery. The Director of Nursing indicated that the nursing assistant responsible for the resident was unaware of the NPO order and had obtained the tray from the kitchen, leading to the deficiency in care.
Failure to Provide Adequate Supervision During Meals
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for two residents who required assistance while eating. Resident ID #368, who has a history of dysphagia, Parkinson's disease, and pneumonitis due to aspiration, was observed eating without supervision on multiple occasions. Despite having a physician's order for 1:1 supervision during meals, the resident was left alone, consuming unthickened liquids contrary to the prescribed nectar thick consistency. Staff members, including nursing assistants and registered nurses, were unaware of the supervision requirement, and the resident's care plan did not reflect the need for 1:1 supervision. Resident ID #55, diagnosed with dementia and muscle weakness, also required supervision or assistance with eating. The care plan did not document this need, and the resident was served food that was not cut into bite-sized pieces as ordered. Observations revealed the resident struggling with improperly prepared meals, leading to coughing and difficulty eating. Staff interviews confirmed a lack of awareness regarding the resident's dietary needs and supervision requirements, with the Director of Nursing Services unable to provide evidence of compliance with the physician's diet order. The deficiencies in supervision and adherence to dietary orders for both residents placed them at risk for serious harm. The facility's failure to ensure staff awareness and compliance with physician orders and care plans contributed to these lapses in care. Interviews with various staff members, including nursing assistants, registered nurses, and therapists, highlighted a systemic issue of communication and documentation regarding residents' specific needs during meals.
Failure to Conduct Annual Performance Evaluations for Nursing Assistants
Penalty
Summary
The facility failed to conduct annual performance evaluations for its nursing assistants, as required. A review of personnel files revealed that no performance evaluations had been completed within the last 12 months for five nursing assistants: Staff G, K, L, M, and N. These staff members had been employed since various dates ranging from 2019 to 2022. During an interview with the Director of Nursing Services, it was confirmed that there was no evidence of completed evaluations for these employees within the specified timeframe.
Food Storage and Safety Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and distributed in accordance with professional standards for food service safety. During an initial tour of the kitchen, surveyors observed several items in the walk-in refrigerator that were either past their use-by dates or not labeled and dated, including sour cream containers, a container of vanilla yogurt, Swiss cheese slices, French dressing, a piece of salmon, and white fish fillets. In the walk-in freezer, items such as frozen burgers and cut sausage were found with freezer burn and were not labeled or dated. Additionally, the dry storage area contained a container of honey that was discolored and not dated when opened, as well as frosting spreads that were opened and not dated. In the North unit kitchenette, an opened dairy drink was found without a date. The Food Service Director acknowledged these issues during an interview. Furthermore, the facility did not comply with the Rhode Island Food Code requirement for a 3-bay sink for manually washing, rinsing, and sanitizing equipment and utensils. During a surveyor observation of the main kitchen, there was no evidence of a 3-bay sink being present. The Food Service Director was aware of this requirement and acknowledged that the facility did not have the necessary sink setup. These deficiencies indicate a failure to adhere to established food safety protocols, potentially compromising the safety and quality of food served to residents.
Infection Control Deficiencies in Water Management, Hand Hygiene, and Linen Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies identified during a survey. The facility did not implement a water management program (WMP) based on industry standards or CDC guidelines to prevent Legionella disease. Laboratory results showed Legionella bacteria levels above acceptable limits in certain water stations, but the Maintenance Director was unaware of the need for control measures. Additionally, the facility's water management binder lacked evidence of a water flow assessment to identify areas where Legionella could grow, and there was no documentation of regular flushing of infrequently used fixtures. The facility also failed to implement proper hand hygiene practices for a resident diagnosed with Clostridium difficile (C. diff). Staff members were observed using hand sanitizer instead of washing their hands with soap and water after providing care to the resident, despite the known requirement for soap and water hand hygiene in such cases. The staff involved were either unaware of the resident's C. diff status or did not follow the correct hand hygiene protocol, as confirmed by interviews with the staff and the Director of Nursing Services. Furthermore, the facility did not adhere to appropriate infection control practices regarding the handling and storage of soiled linen. A staff member was observed carrying unbagged, soiled towels from a resident's room and placing them in an overflowing linen bin, which could not be closed. This practice was acknowledged by the staff involved and recognized as an infection control concern by the Director of Nursing Services. The failure to bag soiled linen in the resident's room and the presence of an overflowing linen bin posed a risk of contamination and infection spread within the facility.
Failure to Notify Physician and Follow Medication Orders
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice by not notifying the physician about unavailable medications for two residents and not following a physician's order for medication parameters for another resident. Resident ID #6, admitted with gastro-esophageal reflux disease, had a physician's order for Saccharomyces boulardii to be administered twice daily. However, the medication was unavailable for several days, resulting in 14 missed doses, and there was no evidence that the physician was notified. Similarly, Resident ID #33, readmitted with a urinary tract infection, missed 7 doses of the same medication due to unavailability, and again, the physician was not informed. Additionally, the facility did not adhere to a physician's order for Resident ID #39, who was diagnosed with hypertension. The order specified that metoprolol tartrate should be administered only if the resident's systolic blood pressure was above 110 and heart rate above 55. However, the medication was administered on days when the systolic blood pressure was below the specified threshold, and there was no documentation of the resident's heart rate being checked prior to administration. Staff interviews confirmed these lapses in following the physician's orders and documenting necessary parameters.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and label drugs and biologicals in accordance with accepted professional principles, as observed during a survey. On the Rehab Unit, a Certified Medication Technician (CMT) was found to have pre-poured medications into plastic cups labeled with room numbers, which is against facility policy. Additionally, expired multivitamins and improperly stored Latanoprost eye drops were found on the medication cart. On the North Unit, another CMT was observed pre-pouring medications and labeling them with room numbers. In the medication storage room, a vial of Tuberculin protein derivative was found to be expired, and a bottle of Lorazepam was opened but not dated, despite manufacturer instructions to discard after a certain period. Further observations in the medication storage room on the Rehabilitation unit revealed another vial of Tuberculin protein derivative that was opened and not dated. Interviews with staff confirmed these practices, with acknowledgments that medications were pre-poured, expired medications were not discarded, and opened medications were not dated. The Director of Nursing Services confirmed that pre-pouring medications is not allowed and that medications should be dated when opened and discarded when expired.
Failure to Implement Psychiatric Recommendations for Resident Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The resident, who was admitted in January 2024 with a diagnosis of major depressive disorder, had a care plan dated April 15, 2024, indicating a risk for changes in mood and behavior due to anxiety and depression. A geriatric psychology document from April 6, 2024, recommended Trazodone 12.5 mg as needed for increased anxiety. However, there was no evidence that this recommendation was communicated to or reviewed by a physician. The resident exhibited signs of increased anxiety and depression, as noted in progress notes from April 24, 2024, and May 1, 2024, where the resident refused to shower and be weighed, respectively. On May 3, 2024, a nurse practitioner noted increased anxiety and depression and suggested increasing scheduled Trazodone. Interviews with staff, including a registered nurse and the nurse practitioner, revealed that the recommendation for Trazodone was documented but not acted upon, as there was no evidence of physician notification or order implementation.
Failure to Provide 1:1 Feeding Assistance
Penalty
Summary
The facility failed to ensure that the medical care of a resident, who required 1:1 feeding assistance due to dysphagia and pneumonitis, was properly supervised by a physician. The resident was admitted in June 2024 with a physician's order for 1:1 feeding assistance and aspiration precautions, signed on June 7, 2024. However, during observations on June 11 and June 12, 2024, the resident was seen eating breakfast without staff supervision. The resident's physician admitted to being unaware of the 1:1 supervision requirement, despite having signed the order, as she did not review each order individually before signing. The Director of Nursing Services expressed an expectation that physicians should review orders individually before signing them.
Failure to Provide Appropriate Diets for Residents
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet individual needs for two residents. Resident ID #55, who has severe cognitive impairment and bilateral upper extremity impairments, was observed receiving meals that did not comply with the physician's dietary order for soft, bite-sized foods. On multiple occasions, the resident was served whole and hard food items such as a muffin, sausage link, clam cakes, and bacon, which were not cut into bite-sized pieces and were not soft as required. Staff interviews revealed a lack of awareness and adherence to the resident's dietary needs, with the Director of Nursing Services unable to provide evidence that the resident received the appropriate diet. Resident ID #368, diagnosed with dysphagia and requiring nectar thick liquids and a pureed diet, was observed consuming unthickened coffee and milk, contrary to the physician's order. The resident's dietary needs were clearly documented, yet staff failed to ensure the liquids were thickened as required. Interviews with nursing assistants and the speech therapist confirmed the oversight, and the Director of Nursing Services acknowledged the failure to follow the physician's diet order. These deficiencies highlight a lack of compliance with dietary orders, potentially compromising resident safety.
Latest citations in Rhode Island
The facility failed to follow physician orders for post-fall care for three anticoagulated residents who experienced falls. One resident on a blood thinner with a head injury was ordered to be transferred to the ED after a telehealth evaluation, but an LPN did not send the resident, citing instructions to contact a supervisor first and inability to reach that supervisor. For two other residents on anticoagulants, providers ordered intensive neuro checks (every 15 minutes, then every 30 minutes, then hourly, then every 4 hours), but staff instead performed neuro checks only once per shift for 72 hours. The DON and Medical Director acknowledged that the transfer and monitoring orders were not implemented as written.
A resident with intact cognition and psychiatric diagnoses sustained a left eyebrow laceration when another resident with a documented history of escalating aggressive and threatening behaviors struck them with a cane during a hallway dispute. The aggressive resident had multiple prior documented incidents, including verbal threats to kill others, attacking a roommate with a cane over TV volume, throwing objects during activities, and throwing a lunch plate at staff. Despite these events, the care plan was not updated with interventions to address physical aggression toward other residents, and a psychiatric recommendation for PRN trazodone for agitation, anxiety, and insomnia was only implemented as PRN for insomnia. The failure to assess, monitor, and implement effective interventions for the aggressive resident’s behaviors led to the assault and injury and, per the report, placed this and other residents at risk of serious physical and psychosocial harm.
A resident with impulse disorder, mood and anxiety diagnoses, and a history of escalating verbal and physical aggression had multiple documented incidents of threats, object throwing, and assault with a cane. Despite a psychiatric consult recommending PRN trazodone for agitation, anxiety, and insomnia, the provider order listed insomnia only, and the care plan was not updated with specific interventions to address the resident’s physically aggressive behaviors after several documented events. Subsequently, the resident struck another resident with a cane, causing a facial laceration that required wound closure and ongoing treatment.
The facility failed to properly screen and document clearance for a NA with disqualifying criminal history information before hire, as required by its abuse, neglect, and exploitation policy. A BCI check showed disqualifying information, yet the NA was hired, completed orientation, and worked independently based only on verbal disclosure of an old drug-related charge, without written details or verification. Later, a staff member reported witnessing this NA grab a resident’s face and kiss the resident on the lips, and a community complaint alleged inappropriate interactions with the same resident, prompting involvement of local police.
A resident with anxiety disorder and PTSD was unable to attend meals and activities with peers because the facility lost the resident's clothing after it was sent to laundry. The resident was observed in a hospital gown with only a few clothing items in the room, and the record lacked an admission inventory of belongings. The DON/Administrator reported that laundry was handled by an outside vendor without a tracking system or item documentation.
A resident with dementia and severely impaired cognition was subjected to repeated non-consensual kissing on the lips by an NA, who entered the resident’s room during care, verbally expressed affection, and then kissed the resident on the mouth on at least two separate occasions witnessed by staff. One staff member delayed reporting the first incident due to fear of the NA. These actions occurred despite a facility policy defining sexual abuse as any non-consensual sexual act and requiring protections of residents’ rights and well-being.
Failure to investigate allegations of resident-to-resident sexual inappropriateness: A resident with dementia and TBI was documented as being inappropriate with another resident, and psych notes later described increased sexually inappropriate behaviors toward other residents. Staff interviews showed the resident had been observed touching others and needing frequent redirection, but the DON, ADON, and Administrator acknowledged the facility did not complete an investigation or recognize the allegation as possible abuse.
A resident with dementia and a hearing deficit did not receive ear care as ordered because the chart lacked the Debrox order and the ear was flushed before the intended Debrox course was completed. In a separate incident, staff witnessed inappropriate kissing of a resident with dementia, but the allegation was not reported to the provider and the care plan was not updated. A third resident’s wound care was also not completed as ordered when an RN used normal saline instead of the prescribed Vashe wound wash.
A resident with migraines and chronic pain did not receive timely pain management after repeatedly reporting a migraine and appearing in visible distress. An NA notified an LPN, an RN said she could not access the med cart, and the resident continued waiting while the LPN was off the unit; the PRN migraine medication was not given until 40 minutes after the first complaint. The DON acknowledged the resident should not have waited that long for pain medication.
A resident missed 6 doses of a prescribed antibiotic, and the MAR did not show that the provider was notified. The RN acknowledged the missed doses and said they should have been reported, while the Medical Director stated she was unaware of the missed doses and would have extended the antibiotic course if informed. The DON also confirmed the missed doses and expected provider notification for any missed antibiotic dose.
Failure to Follow Post-Fall Physician Orders for Anticoagulated Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement physician orders for post-fall care, including hospital transfer and neurological monitoring, for residents on anticoagulant therapy. One resident with atrial fibrillation on Xarelto experienced an unwitnessed fall with a scalp laceration and head lump. The on-call provider, after a telehealth evaluation, ordered transfer to the ED and wrote an order directing that the resident be sent to the hospital. The resident was not transferred as ordered, and an additional order for vital signs and neuro checks every shift for 72 hours after the fall was not completed as ordered on one of the shifts. The LPN caring for this resident stated she did not send the resident to the ED because she had been instructed to call a supervisor before sending residents out, and she was unable to reach the supervisor during the shift. A second resident, also with atrial fibrillation and on Xarelto, had an unwitnessed fall with injury. The on-call provider was notified and ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, then every four hours for an additional 24 hours. A physician’s order reflecting this schedule was scanned into the EMR. However, the neuro checks were not completed as ordered; instead, they were performed only once per shift for 72 hours. The RN who authored the progress note documented the fall and the resident’s anticoagulant use, and later stated she could not remember why she did not transcribe and complete the neuro checks as ordered. A third resident with atrial fibrillation on Apixaban had a non-injury fall after attempting to walk independently. The on-call provider ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, and then every four hours for an additional 24 hours, and this order was scanned into the EMR. The record did not show that these neuro checks were completed as ordered; instead, neuro checks were documented only once per shift for 72 hours. The Medical Director stated he would have expected the first resident to be transferred to the ED as ordered and that the facility should not override a provider’s order. The DON acknowledged that the transfer order and the ordered monitoring for the first resident were not followed as written, and that for the second and third residents, staff performed only once-per-shift neuro checks instead of the more frequent monitoring ordered by the providers.
Failure to Manage Escalating Aggression Leading to Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident, Resident ID #1, from abuse by another resident with a known history of escalating aggression, Resident ID #2. Resident ID #1 was admitted in October 2025 with diagnoses including paranoid schizophrenia and adjustment disorder with mixed anxiety and depressed mood, and had a BIMS score of 14/15, indicating intact cognition. On 4/27/2026, progress notes documented that Resident ID #1 was on the receiving end of a physical altercation with another resident and was found with a deep bleeding abrasion to the left eyebrow. A subsequent nursing note described a new laceration to the left eyebrow measuring 0.5 cm by 2.0 cm by 0.1 cm, related to a resident-to-resident incident, for which wound closure strips were applied. Resident ID #1 requested police involvement and a police report, and refused transfer to the hospital for sutures. Resident ID #2 had been admitted in December 2024 with multiple psychiatric and behavioral diagnoses, including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed a BIMS score of 13/15 and documented both physical and verbal behaviors during the look-back period. Progress notes over several months recorded a pattern of escalating aggressive and threatening behaviors: on 9/13/2025, Resident ID #2 threatened to slit another resident’s throat and made additional threats toward staff; on 11/7/2025, the resident was involved in a verbal dispute with raised voice, name-calling, and verbal threats; on 12/28/2025, after another resident struck Resident ID #2 with a helmet, Resident ID #2 was overheard threatening to kill that resident if touched again. On 2/21/2026, the on-call provider documented that Resident ID #2 attacked a roommate with a cane over TV volume and required ER transfer for psychiatric evaluation. Subsequent notes on 3/9/2026 and 4/10/2026 described the resident throwing poker chips on the floor, yelling and swearing at staff and residents, and throwing a lunch plate across the nurses’ station at a nursing assistant due to dissatisfaction with portion size. Despite this documented pattern, the care plan for Resident ID #2, dated 1/16/2025, only indicated a behavior problem of being verbally aggressive toward staff with resident-to-resident altercations on 12/28/2025, 2/21/2026, and 4/27/2026, and record review failed to show added interventions to mitigate the risk of physical aggression toward other residents after the 2/21/2026 cane attack and the object-throwing incidents on 3/9/2026 and 4/10/2026. A psychiatric evaluation on 4/23/2026 recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order entered on 4/24/2026 specified trazodone 25 mg twice daily as needed only for insomnia, and record review did not show that agitation and anxiety were included as indications for use. During interviews, the RNP and the DON stated it was their expectation that agitation and anxiety would have been included in the trazodone order, and the DON was unable to provide evidence that the care plan had been updated with interventions to address Resident ID #2’s physically aggressive behaviors documented on 2/21/2026, 3/9/2026, and 4/10/2026. On 4/27/2026, the DON documented that Resident ID #2 was ambulating down the hall toward his/her room while Resident ID #1 was walking in the opposite direction, and the two residents began a verbal dispute. Before staff could intervene, Resident ID #2 used his/her cane to make contact with Resident ID #1, resulting in the eyebrow laceration that required steri-strips and ongoing wound treatment. A police incident report recorded that Resident ID #1 stated being struck with a walking cane, wanted to press charges, and that Resident ID #2 admitted to striking Resident ID #1, leading to an arrest on one count of felony assault with a dangerous weapon. The facility’s failure to assess, monitor, and implement effective interventions for Resident ID #2’s known and escalating aggressive behaviors, including failure to update the care plan after prior incidents and failure to fully implement psychiatric recommendations, resulted in this resident-to-resident altercation and injury, and the report states that this failure placed Resident ID #1 and other residents at risk of serious physical and psychosocial harm.
Failure to Implement Psychiatric Recommendations and Update Behavior Care Plan Leading to Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health services and care planning for a resident with a documented history of psychiatric conditions and aggressive behaviors. The resident was admitted in December 2024 with diagnoses including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed intact cognition with a BIMS score of 13/15 and documented physical and verbal behaviors during the look-back period. Over time, multiple behavioral incidents were recorded, including threats to slit another resident’s throat during a smoking session, verbal disputes with name-calling and threats, and a statement to another resident that if touched again the resident would be killed. Further documentation showed escalating behaviors, including an incident where the resident attacked a roommate with a cane over television volume and required ER transfer for psychiatric evaluation, throwing poker chips and yelling when not winning at Bingo, causing the roommate to avoid the shared bathroom due to inappropriate comments and frustration over the light being turned on at night, and throwing a lunch plate across the nurses’ station at a nursing assistant over portion size. The care plan, initiated in January 2025 for verbal aggression and resident-to-resident altercations, did not contain added interventions to address the resident’s physically aggressive behaviors toward others after the incidents on 2/21/2026, 3/9/2026, and 4/10/2026. The DNS later could not provide evidence that the care plan had been updated with interventions to mitigate the risk of these physically aggressive behaviors or to guide staff in ensuring the safety of other residents. On 4/23/2026, a psychiatric evaluation recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order dated 4/24/2026 implemented trazodone 25 mg twice daily as needed for insomnia only, and the record lacked evidence that agitation and anxiety were included as indications for use as recommended by the consulting psychiatrist. Both the RNP and the DNS stated it was their expectation that the trazodone order would have included agitation and anxiety. Following this incomplete implementation of the psychiatric recommendation and the lack of updated behavioral interventions in the care plan, a resident-to-resident altercation occurred on 4/27/2026 in which the resident struck another resident with a cane, causing a laceration to the left eyebrow that required closure with steri-strips and ongoing wound treatment.
Failure to Properly Screen and Clear NA with Disqualifying Criminal History
Penalty
Summary
The facility failed to ensure that a prospective employee was properly screened and cleared for a history of abuse, neglect, exploitation, or misappropriation of resident property before hire. A nursing assistant, identified as Staff A, was hired on 11/18/2025 and was working independently as a NA. Prior to hire, a Bureau of Criminal Identification (BCI) check dated 11/6/2025 showed that Staff A had disqualifying information under federal and state law. Surveyor review after discovery of the positive BCI revealed that Staff A had an extensive criminal history. Despite this, the facility proceeded with the hire and allowed Staff A to complete orientation and work independently without obtaining or maintaining documentation specifying the nature of the disqualifying information, contrary to the facility’s Abuse, Neglect and Exploitation Policy, which requires screening and documentation of proof that such screening occurred. Subsequently, a facility-reported incident submitted on 4/17/2026 documented that a staff member reported witnessing Staff A grab a resident’s face and kiss the resident on the lips. A community-reported complaint submitted on 4/22/2026 alleged inappropriate interactions between the same NA and the same resident, and included a local police incident report indicating the resident’s family intended to pursue charges related to the incident. During interviews, the Human Resource Director stated that Staff A had disclosed disqualifying information related to a prior drug-related charge from about ten years earlier, but acknowledged there was no documentation specifying the nature of the disqualifying information and that this was known only by word of mouth. The Administrator stated she was aware that the BCI contained disqualifying information and that she exercised her own judgment in proceeding with the hire, and further acknowledged she did not receive documentation detailing the disqualifying information until it was brought to her attention by the surveyor.
Failure to Maintain Resident Clothing and Dignity
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity when the resident was unable to attend meals and activities with other residents because of a lack of appropriate clothing. The resident was admitted in May 2025 with diagnoses including anxiety disorder and post-traumatic stress disorder, and a care plan revised on 8/25/2025 described the resident as highly social and willing to participate in a variety of activities, with an intervention to provide reminders of scheduled events. During observation on 4/29/2026, the resident was found in the room wearing a hospital gown while other residents were in the dining room for lunch. Only one pair of pants and two T-shirts were observed in the room. The resident stated that the facility lost all of the resident's clothing, including shirts, pants, shorts, and socks, after they were sent to laundry services several months earlier and were never returned. The resident reported that the Administrator was told about the missing clothing, but no follow-up occurred and the clothing was neither located nor replaced. The record did not contain an admission inventory list of the resident's belongings, and the Administrator stated that laundry was handled by an outsourced company without a tracking system or documentation identifying which items belonged to which resident.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse when a nursing assistant (NA) was observed kissing the resident on the lips on more than one occasion. The resident, identified as having dementia and a Brief Interview for Mental Status (BIMS) score of 0/15 indicating severely impaired cognition, had been admitted in March 2026. On one occasion, a Certified Medication Technician (CMT) reported that while she was assisting the resident with breakfast, the NA entered the room, verbally expressed affection for the resident, made a kissing noise, leaned forward, and kissed the resident on the lips. This incident made the CMT uncomfortable, and she later discussed it with another NA. A separate staff member, another NA, reported that two days earlier she had observed the same NA enter the resident’s room while morning care was being provided, ask the resident if they remembered her, state that she loved the resident, then lean toward the resident, make a kissing sound, and kiss the resident on the mouth with full lip-to-lip contact. This second NA did not report the incident at the time because she was fearful of the NA involved and only came forward after learning of the later incident. The facility’s abuse, neglect, and exploitation policy defined sexual abuse as a non-consensual sexual act of any type with a resident and required protections for each resident’s health, welfare, and rights, as well as screening of potential employees for a history of abuse. Despite this policy, the resident with severely impaired cognition was subjected to repeated non-consensual kissing by the NA.
Failure to Investigate Allegations of Resident-to-Resident Sexual Inappropriateness
Penalty
Summary
The facility failed to ensure that allegations made by residents were recognized as possible abuse by staff and that all allegations were investigated for Resident ID #41, who was admitted with diagnoses including dementia and traumatic brain injury. A facility policy titled, Abuse, Neglect and Exploitation, stated that an immediate investigation is warranted when suspicion of abuse, neglect, exploitation, or reports of abuse, neglect, or exploitation occur. A progress note written by an RN documented that a resident reported Resident ID #41 was being inappropriate with another resident. Subsequent records included psychiatric evaluations stating the resident was being seen due to increased sexually inappropriate behaviors toward other residents and that sexual impulses may present an unsafe environment for other patients in the facility. Staff interviews revealed that Resident ID #41 had been observed touching other residents' shoulders and hands and required frequent redirection. The RN who documented the incident stated the behavior involved an attempted hug without contact and that both residents were separated and assessed, while the ADON and DON acknowledged they were unaware of the behavior or that the facility had not investigated the allegations. The Administrator also acknowledged that an investigation had not been completed to determine what sexually inappropriate behavior had occurred and that staff did not identify the allegation as possible abuse or investigate it immediately.
Failure to Follow Orders, Report Abuse, and Perform Ordered Wound Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for a resident with dementia and anxiety disorder who had a hearing deficit and complained of right ear wax buildup. The medical record showed an order for Debrox ear drops and a separate order to flush the right ear with warm water two times a day following Debrox usage for 5 days, but the record did not include a physician order for the Debrox solution. The April 2026 MAR showed the resident’s right ear was flushed six times, and the resident stated that the right ear still felt blocked. The RN acknowledged flushing the ear and was unaware whether Debrox had been given, while the DON stated the order had been entered incorrectly and that the ear should not have been flushed before Debrox administration. The NP stated the intended order was for Debrox twice daily for five days before irrigation and that she would not have ordered daily ear flushing. The facility also failed to report an allegation of abuse and failed to update the care plan for a resident with dementia after staff reported inappropriate interactions with a nursing assistant. A community complaint and police incident report indicated the family wanted to press charges, and the Administrator and DON confirmed that staff had reported witnessing the nursing assistant kiss the resident on two occasions. The record did not show that the allegation was reported to the provider, and the comprehensive care plan was not updated to reflect the allegation or any interventions related to the incident. The NP stated she was unaware of the incident and would have expected to be notified, and the ADNS acknowledged that the provider had not been notified and the care plan had not been updated. The facility further failed to follow a wound care order for a resident readmitted with peripheral vascular disease and cellulitis of the lower limb. The physician ordered cleansing open areas on the left lower leg with Vashe wound wash, applying xeroform to the wound bed, and wrapping with kling. During observation, the RN performing wound care did not use Vashe wash and instead cleansed the wound with normal saline. The RN acknowledged using normal saline rather than the ordered cleanser, and the DON stated she would expect the nurse to follow the wound orders as written.
Delayed Pain Medication for Resident with Migraine
Penalty
Summary
Safe, appropriate pain management was not provided for Resident ID #17, who was admitted with diagnoses including migraines and chronic pain. The resident’s care plan dated 4/20/2026 included a goal for the resident to verbalize adequate pain relief and an intervention to respond immediately to any complaint of pain. The physician ordered Butalbital-APAP-Caffeine 50-300-40 mg, 1 capsule every 12 hours as needed for migraine pain. On 4/29/2026 at 10:30 AM, the resident was observed in the hallway complaining of a migraine, moaning in pain, and holding his/her head. At 10:34 AM, an NA reported to an LPN that the resident wanted pain medication, and at 10:37 AM the resident continued to complain of migraine pain and told an RN about the pain, but the RN stated she did not have keys to the medication cart and could not get any pain medication. The resident continued to complain of severe head pain, returned to the room to lie down at 10:40 AM, and the LPN was still off the unit at 10:42 AM. The resident was not assessed when the LPN returned, and the medication was not administered until 11:10 AM, 40 minutes after the initial complaint. The resident later reported pain rated 7 out of 10, and the DON acknowledged that a resident should not wait 40 minutes for pain medication.
Missed Antibiotic Doses Not Reported to Provider
Penalty
Summary
The facility failed to ensure that Resident ID #17 was free from significant medication errors when the resident missed 6 doses of a prescribed antibiotic. The resident was admitted in April 2026 with diagnoses including surgical aftercare and complication of surgical and medical care, and had a physician order dated 4/3/2026 for Cefadroxil 500 mg by mouth twice daily for 14 days. Review of the April 2026 MAR showed missed doses on 4/3 at 8:00 PM, 4/6 at 8:00 PM, 4/11 at 8:00 PM, 4/12 at 8:00 AM, 4/14 at 8:00 PM, and 4/17 at 8:00 AM. The record did not show that the provider was notified of the missed antibiotic doses. During interview, the RN acknowledged the 6 missed doses and stated they should have been reported to the provider. The Medical Director stated she was unaware of the missed doses and said she would have extended the antibiotic course if she had known. The DON also acknowledged the missed doses and stated she would expect the provider to be informed if a resident misses any dose of an antibiotic.
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