Lincolnwood Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in North Providence, Rhode Island.
- Location
- 610 Smithfield Road, North Providence, Rhode Island 02904
- CMS Provider Number
- 415035
- Inspections on file
- 63
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 13 (2 serious)
Citation history
Health deficiencies cited at Lincolnwood Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to report an accident with serious injury and subsequent death to required authorities. A resident with a history of seizures and muscle weakness sustained an unwitnessed fall, was found on the left side with a left elbow skin tear, and later complained of left shoulder and rib pain. An LPN notified a provider, obtained orders for imaging, and later reported to an NP that the resident had a fall with a suspected left clavicle fracture, resulting in an order to transfer the resident to the ER. A CT scan did not confirm a clavicle fracture but showed acute fractures of ribs on both sides. The resident later died, and the DON acknowledged the acute rib fractures from the fall but could not provide evidence that the death and associated injuries were reported to the State Survey Agency as required by State law.
A resident with acute and chronic respiratory failure with hypercapnia returned from the hospital with discharge orders to continue nighttime BiPAP therapy with individualized settings, but no BiPAP order was initiated on readmission and there was no evidence the physician was contacted about this therapy. A subsequent order to follow up on BiPAP needs was documented as completed over multiple days, yet records show the resident did not receive BiPAP for 18 days. An LPN who worked the overnight shift throughout this period reported being unaware of the BiPAP requirement until the device was delivered by the oxygen vendor, and the Medical Director stated he would have expected the resident to receive BiPAP upon readmission.
The facility did not ensure that food and nutrition service personnel had the required Food Manager's Certification during all meal preparation and service times. Surveyors found that cooks in charge of preparing and serving meals held only Food Handlers Certifications, while the FDA Food Code requires the person in charge to be a certified Food Protection Manager. Review of dietary schedules showed multiple dates when no certified Food Manager was present during breakfast, lunch, or dinner, and the FSD acknowledged that only half of the cooks were certified and that there were scheduled periods without certified coverage.
Hallway handrails were found in disrepair and becoming detached from the wall on multiple units. A surveyor observed one railing move when leaned against and noted it was not secured on one side, and additional handrails were observed loose near stairwells, storage areas, the elevator, and resident rooms. The Mnt Dir acknowledged the condition of the handrails.
Failure to provide privacy during wound care. An LPN was observed preparing and performing a dressing change for a resident with a coccyx wound while the room door was open and the privacy curtain was not drawn. The resident was without pants, wearing only a brief, and was exposed to people passing in the hallway. The LPN acknowledged privacy should have been provided, and the DON could not show that privacy was ensured during the procedure.
Failure to properly assess, document, and treat pressure ulcers: Staff did not document weekly measurements or full wound descriptions for a resident with an unstageable heel PU and a resident whose coccyx blisters progressed to a stage 3 PU. For one resident, the wound was not identified on weekly skin assessments; for the other, staff continued using skin prep after the wound opened and did not implement the wound provider’s new treatment order right away.
BiPAP care was not provided consistently for two residents. One resident with CHF had a BiPAP ordered for bedtime and naps, but surveyors found brown particles in the mask, discoloration in the tubing, and an empty humidifier chamber; the record did not show evidence that the humidifier was filled with distilled water or that cleaning orders were in place. Another resident with OSA and chronic respiratory failure returned from the hospital without a BiPAP order being initiated, and surveyors observed the resident sleeping without the BiPAP in use until the order was entered later.
Surveyors found that the facility failed to implement Enhanced Barrier Precautions (EBP) in accordance with CDC guidance and facility policy for two residents who had central venous catheters (CVCs) for in-house dialysis. Both residents had physician orders for regular monitoring of their right chest CVC access sites and dressings, but there were no EBP orders in their records. In one case, EBP signage and PPE were posted at the room entrance, but a regional clinical leader stopped the use of PPE and stated the resident did not require EBP, explaining the setup was for an anticipated new admission. In an interview, the Regional Director of Clinical Services acknowledged that the facility does not follow EBP for residents with CVCs for dialysis, despite CDC recommendations that residents with indwelling medical devices, including central lines, be placed on EBP.
A resident with a history of smoking and falls, while on oxygen therapy, was able to use a personal lighter in their room, resulting in the ignition of oxygen tubing and a minor fire that damaged the floor and equipment. The facility was aware of the resident's risk factors but did not provide evidence of adequate supervision or environmental safeguards to prevent this accident.
A resident was not protected from a significant medication error due to a failure in the medication administration process.
A resident was admitted without a doctor's order and was not under a physician's care at the time of admission, as required. The facility did not follow the necessary procedures to ensure medical oversight upon admission.
A resident with end stage renal disease was admitted with a physician's order for Miralax to be given as needed (PRN), but due to a transcription error by an LPN, the medication was administered daily instead. The resident, who was cognitively intact, reported never having taken the medication daily before and did not request the change. Staff interviews confirmed the error, and facility leadership could not provide evidence that the medication was given as ordered.
A resident with end stage renal disease requiring dialysis did not have their total daily fluid intake documented as ordered, with only nursing fluids recorded and no evidence of full compliance with a 1000 ml fluid restriction. Additionally, Sevelamer Carbonate, prescribed to be given with meals, was not administered on several dialysis days due to the resident's absence, and the provider was not notified of these missed doses. Facility staff and leadership were unable to provide evidence that physician's orders for fluid restriction and medication administration were followed.
A resident with paraplegia, dependent on two staff for transfers and requiring a mechanical lift, fell during a transfer when a sling strap slipped off the Hoyer lift. The resident sustained a femur fracture and a sacral fracture after striking the lift, with staff and the resident confirming the strap was not properly secured. Facility leadership could not provide evidence of a safe transfer or a resident interview following the incident.
The facility failed to maintain an effective infection prevention and control program, with staff not adhering to PPE protocols for residents on droplet precautions. A resident with Flu A had staff enter without proper PPE, and another with COVID-19 had staff enter without eye protection. Additionally, a resident with a PICC line had a nurse touch the dressing without gloves, breaching infection control practices.
The facility failed to implement an antibiotic stewardship program, as evidenced by the lack of antibiotic reviews or time-outs for residents prescribed antibiotics. An Infection Preventionist confirmed that the facility did not conduct antibiotic time-outs, indicating a systemic issue in infection control.
A resident with a PICC line had a dressing improperly managed by an LPN, who attempted to remove it with soiled gloves and re-secure it without gloves, breaching sterile procedure. The LPN acknowledged the error, and the DON confirmed the improper actions.
A facility failed to follow physician orders for a resident's wound care, resulting in a soiled dressing and improper documentation. The resident, with Alzheimer's and adult failure to thrive, had a wound dressing that was not changed daily as ordered. Observations revealed crusted drainage and an embedded dressing, contrary to the documented treatment. Interviews confirmed the discrepancy between the documented and actual care provided.
A resident admitted with a pressure ulcer on the coccyx did not receive timely assessment and documentation of the wound. The facility failed to measure or describe the ulcer upon admission, with documentation only occurring a week later. The resident's care plan included interventions for wound assessment, but these were not implemented promptly, as confirmed by the DON.
A resident experienced significant weight loss, and the facility failed to follow its policy for re-weighing and notifying the dietician. Despite the resident's severe weight loss, no interventions were implemented, and the dietician was not re-evaluated after the weight discrepancies. Staff interviews confirmed the oversight in following the facility's policy.
A facility failed to ensure proper bed elevation for a resident receiving continuous G-tube feeding, risking aspiration. Despite a care plan and physician's order to keep the bed elevated at 30-45 degrees, surveyors observed the bed not elevated during feeding. Staff acknowledged the oversight, and the resident was seen coughing, indicating potential aspiration risk.
A resident with Alzheimer's and adult failure to thrive had a soiled wound dressing that was not changed as per physician's orders. The TAR was inaccurately signed off by LPNs as if the treatment was completed. Interviews revealed the LPNs did not perform the treatment and were unaware of the dressing's date. The DON confirmed the TAR should not be signed off if treatment was not completed.
A resident was discharged with another resident's medications due to a failure in medication reconciliation by an LPN. The error was discovered when a home care nurse reviewed the medications, finding that the discharged resident had taken Atorvastatin, which was not prescribed to them. The DON could not explain the lack of reconciliation or discharge instructions, posing a risk of serious harm.
A resident with atrial fibrillation and pneumonia did not receive prescribed doses of Cefpodoxime due to staff oversight. The medication was available, but the responsible nurse failed to administer it and did not inform the provider of the missed doses. The DON and the resident's physician were unaware of the issue, highlighting a lapse in communication and adherence to medical orders.
A resident at high risk for falls, requiring two-person assistance for bed mobility, fell and sustained head injuries due to inadequate supervision. Only one NA was present during care, unaware of the two-person requirement, as indicated in the care plan and Kardex. Staff interviews revealed communication errors regarding the resident's care needs.
The facility failed to monitor and record intake and output for two residents with catheters, as required by their care plans. One resident had a suprapubic catheter and was readmitted with a urinary tract infection, while the other had a foley catheter and was readmitted with chronic kidney disease. The Director of Nursing Services acknowledged the lack of documentation during a surveyor interview.
A resident was transferred to a hospital without immediate notification to their family, as required. The resident, who had conditions including a urinary tract infection and MRSA, was sent to the hospital due to no urinary output and abdominal pain. The family was not informed until a day later, and the facility staff could not provide evidence of timely notification.
A resident received their roommate's medications, including hydralazine and labetalol, due to a failure to perform the required five checks. This error resulted in the resident experiencing hypotension, although they were asymptomatic. The incident was acknowledged by the DON, and the resident required IV fluids to address the low blood pressure.
A resident with Alzheimer's was transferred to a hospital due to aggressive behavior, and the facility failed to provide written notice of the bed-hold policy to the resident or their representative. Despite the resident's long-term stay, the facility informed the hospital that no beds were available upon discharge. Interviews revealed a lack of communication and documentation regarding the bed-hold policy, resulting in the resident's room being packed up and no bed available for their return.
A resident with heart failure, end-stage renal disease, and diabetes missed a critical cardiology appointment due to the facility's failure to arrange transportation. Despite orders for follow-up with hematology and a GI consult, these appointments were not scheduled. The cardiology office's attempts to reschedule were unanswered, and staff interviews confirmed the lack of action.
A resident with brain cancer did not receive the correct dosage of chemotherapy medication due to a transcription error by an LPN and a failure by the Pharmacy Consultant to identify the discrepancy during a Medication Regimen Review. The resident was supposed to receive 125 mg of Temozolomide daily but only received 5 mg, as the LPN inaccurately transcribed the order and did not reconcile it with hospital records.
A resident with brain cancer received incorrect chemotherapy dosage and form due to transcription and administration errors. The LPN failed to reconcile hospital discharge orders with the facility's MAR, leading to the resident receiving only 5 mg of Temozolomide instead of the prescribed 125 mg. Additionally, the medication was improperly administered by opening capsules, contrary to guidelines requiring them to be swallowed whole.
A resident with intact cognition was injured after being pushed by another resident with severe cognitive impairment, leading to a hip fracture. The aggressive resident had a history of disruptive behaviors, and the facility failed to implement effective interventions to prevent the altercation, resulting in a deficiency in protecting residents from abuse.
A resident's dignity was compromised when a Nursing Assistant (NA) called them a 'cripple' during care. Despite being instructed to avoid the resident's room, the NA entered twice afterward, leaving the resident feeling degraded and upset. The Director of Nursing Services could not provide evidence that the NA was kept away from the resident as directed.
Failure to Report Resident Fall With Acute Rib Fractures and Subsequent Death to Authorities
Penalty
Summary
The facility failed to report to the appropriate authorities, including the State Survey Agency, an allegation involving an accident that resulted in serious injury prior to a resident’s death, as required by State law. A community complaint submitted to the Rhode Island Department of Health alleged that a resident sustained a fall with injury that required hospital transfer and that diagnostic imaging at the hospital identified three new rib fractures. The resident, who had been readmitted to the facility with diagnoses including seizures and muscle weakness, experienced an unwitnessed fall and was found lying on his/her left side with a left elbow skin tear. A progress note by the on-call provider documented the fall, and a later note by an LPN documented that the resident complained of pain following the fall, refused a meal, and stated, "I am in pain," with assessment findings of pain in the left shoulder and left rib cage. The provider was notified and x-rays of the left shoulder and ribs were ordered. Subsequent documentation by another LPN indicated that the nurse practitioner was informed that the resident had a fall with a left clavicle fracture and that a new order was obtained to send the resident to the emergency room for further evaluation. A CT scan report later failed to show a clavicle fracture but did identify acute fractures of the right first rib and the left second and third ribs. The resident later expired. During surveyor interviews, the Director of Nursing Services acknowledged that the resident sustained acute rib fractures as a result of the fall prior to death and was unable to provide evidence that the facility reported the death and associated serious injuries to the appropriate authorities, including the State Survey Agency, as required under applicable State law governing long-term care facilities.
Failure to Provide Ordered BiPAP Therapy After Hospital Readmission
Penalty
Summary
The facility failed to ensure that positive airway pressure therapy was provided in accordance with professional standards of practice for a resident with acute and chronic respiratory failure with hypercapnia. The resident was originally admitted in February 2026 with a physician’s order dated 2/10/2026 for CPAP at bedtime and as needed for naps, with 4 liters of oxygen and individualized settings, and instructions to verify proper placement and function. The resident was transferred to the hospital on 2/28/2026 with a diagnosis of pleural effusion and returned on 3/12/2026. The hospital continuity of care form dated 3/12/2026 included discharge orders to continue nighttime BiPAP therapy with individualized settings. Upon readmission on 3/12/2026, there was no evidence that an order was initiated to continue BiPAP therapy, nor that the physician was contacted regarding this therapy. A physician’s order dated 3/13/2026 directed staff to follow up in the morning with BiPAP, noting that the family would bring in the device and instructing that the Unit Manager be alerted to follow up with BiPAP needs; this order was signed off as completed from 3/13/2026 through 3/29/2026. Record review, however, failed to show that the resident actually received BiPAP therapy from 3/12/2026 through 3/29/2026, indicating an 18‑day period without the ordered therapy. The weekly schedule showed that an LPN worked the 11:00 PM to 7:30 AM shift nightly on the resident’s unit during this time; in an interview, this LPN stated he was unaware the resident required BiPAP until the device was delivered by the oxygen vendor on 3/30/2026 and acknowledged the resident did not receive BiPAP during his shift from readmission through 3/30/2026. In a separate interview, the Medical Director stated he would have expected the resident to receive BiPAP therapy upon readmission.
Lack of Certified Food Protection Manager Coverage During Meal Service
Penalty
Summary
The facility failed to ensure that support personnel in the food and nutrition services possessed the required competencies and credentials to safely carry out their duties, specifically by not having a certified Food Protection Manager in charge during all meal preparation and service times. Surveyors reviewed the 2022 FDA Food Code, Section 2-102.11, which requires the person in charge to be a certified Food Protection Manager who has passed an accredited program. During an initial kitchen tour, a cook identified as the staff member in charge of food service for the breakfast meal, and the Food Service Director (FSD) later confirmed that the two cooks who prepared and served that breakfast only held Food Handlers Certifications, not Food Manager's Certifications. Further record review of dietary schedules for February and March 2026 showed multiple dates on which no staff member with a Food Manager's Certification was scheduled during one or more of the three daily meals, despite prepared meals being delivered to units during defined breakfast, lunch, and dinner timeframes. The FSD, in the presence of the Regional FSD, acknowledged that only 2 of the 4 cooks on staff had obtained the required Food Manager's Certification and that the facility's staffing schedules included periods when no certified Food Manager was present during meal preparation and service. This lack of appropriately certified personnel during active food preparation and service constituted the deficiency identified by surveyors.
Hallway Handrails Not Secured to Wall
Penalty
Summary
Hallway handrails were not maintained in a safe operating condition on 3 of 4 units observed. During observation, a wall railing to the left of a resident room was noted to move slightly when the surveyor leaned against the wall, and further inspection showed the right side of that railing was not secured to the wall. Additional observations found hallway handrails in disrepair and becoming detached from the wall in multiple locations, including beside stairwell A on the second floor, near the storage room on the second floor south unit, near two resident rooms on the second floor north unit, by the elevator on the third floor north unit, and near two resident rooms on the third floor north unit. The Maintenance Director acknowledged that the handrails in these locations were in disrepair and becoming detached from the walls.
Failure to Provide Privacy During Wound Care
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity during a wound dressing change for a coccyx wound. A physician’s order dated 3/15/2026 directed daily and as-needed cleaning and treatment of the resident’s tailbone wound. During surveyor observation on 3/18/2026 at approximately 10:00 AM, an LPN was seen entering and exiting the room while preparing wound care supplies at the resident’s bedside table, but privacy was not provided: the privacy curtain was not drawn and the room door was left open. The resident was observed without pants, wearing only a brief, and was exposed to individuals passing in the hallway. In interview, the LPN acknowledged that she should have pulled the privacy curtain or covered the resident while going in and out of the room. The DON, in the presence of the Regional Director of Clinical Services, was unable to provide evidence that staff ensured the resident had privacy during the dressing change.
Failure to properly assess, document, and treat pressure ulcers
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for 2 of 5 residents reviewed. Surveyors cited failures in wound assessment, measurement, documentation, and implementation of provider-directed wound care for Resident ID #17 and Resident ID #31. Resident ID #17 was admitted with an unstageable pressure ulcer to the right heel. The care plan identified the resident as having a pressure injury on the right heel and included interventions to document wound length, width, and depth where possible, along with the wound perimeter and wound bed. However, weekly skin assessments dated 3/3/2026 and 3/9/2026 did not identify the right heel ulcer and did not include measurements or a full description of the wound, including location, stage, or the presence of exudates or necrotic tissue. The Unit Manager and the Director of Nursing Services acknowledged that the wound should have been measured weekly and documented on the skin assessments, but could not provide evidence that this occurred. Resident ID #31 was admitted with vascular dementia and had three intact blisters on the coccyx, for which a physician ordered skin prep twice daily. Skin assessments on 2/4, 2/9, and 2/16/2026 documented a blister on the coccyx but did not include measurements or a full wound description. On 2/25/2026, a wound care provider determined the coccyx wound had progressed to a stage 3 pressure ulcer and recommended cleansing with normal saline, applying medicated honey, and covering with a silicone foam dressing daily. The record did not show that these recommendations were implemented until 2/28/2026, and staff continued applying skin prep to the wound site after it had become an open wound. The Unit Manager and Director of Nursing Services acknowledged that blisters should be measured and documented weekly and could not provide evidence that the new wound treatment order was implemented on 2/25/2026 or that the resident received appropriate treatment on 2/26/2026 and 2/27/2026.
BiPAP Care and Order Management Deficiencies
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents who were ordered BiPAP therapy. Resident ID #161 was readmitted with chronic diastolic congestive heart failure and had intact cognition. The physician ordered BiPAP at bedtime and as needed for naps with placement and functioning checks, but the record did not show an order to clean the BiPAP per facility policy. Surveyors observed the resident using the BiPAP while sleeping, and later found small brown particles inside the face mask and a brown discoloration in the tubing. For Resident ID #161, surveyors also observed that the BiPAP humidifier chamber was empty. The resident stated that the BiPAP dries out the face and mouth and that staff do not consistently fill the humidifier with distilled water. The record did not show evidence that the humidifier was filled with distilled water when the device was used, and the UM could not provide evidence that staff were doing so. The facility policy stated that the humidifier should use clean, distilled water and that masks, nasal pillows, and tubing should be cleaned daily. Resident ID #204 was admitted with obstructive sleep apnea and chronic respiratory failure and had a physician order for BiPAP at bedtime and as needed for naps, with 2 liters of oxygen via nasal cannula under the mask and individualized settings. After the resident returned from the hospital, the record did not show that a BiPAP order was initiated on readmission or that the physician was contacted about continuing therapy. Surveyors observed the resident sleeping without the BiPAP in use, and the March 2026 MAR did not show a BiPAP order. The UM stated the resident had not been using the BiPAP because there was no physician order, and the NP acknowledged she wanted the resident to continue BiPAP but did not write the order until later.
Failure to Implement Enhanced Barrier Precautions for Dialysis Residents with Central Lines
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program consistent with CDC guidance and its own policy regarding Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices, specifically central venous catheters (CVCs) used for dialysis. CDC guidance dated June 28, 2024, states that EBP, including gown and glove use during high-contact resident care activities, should be implemented for residents with wounds or indwelling medical devices such as central lines, and that these precautions should remain in place for the duration of the device. The facility’s written EBP policy acknowledges that indwelling medical devices include central lines, but further review showed the facility does not place residents on EBP when they have a central line for dialysis, which is not aligned with CDC guidance. For one resident admitted in December 2021 with end stage renal disease and dependent on in-house dialysis three times weekly, physician orders included monitoring the right chest CVC access site every shift for signs of infection and documenting abnormal findings, but there was no order for EBP despite the presence of the indwelling CVC. Surveyor observation of this resident’s room showed EBP signage and a PPE bin at the entrance, but the Regional Director of Clinical Services stopped the surveyor from donning PPE and stated the resident did not require EBP, explaining the signage and bin were placed in anticipation of a new admission. For a second resident admitted in June 2025 with Parkinson’s disease and dependent on in-house dialysis three times weekly, orders included monitoring the right chest CVC site and dressing every shift, but again there was no EBP order. In an interview, the Regional Director of Clinical Services confirmed that the facility does not follow EBP for residents with a CVC for dialysis, despite acknowledging CDC’s recommendation for EBP for residents with indwelling medical devices, including central lines.
Failure to Prevent Accident Hazard Involving Oxygen and Smoking Materials
Penalty
Summary
A deficiency occurred when the facility failed to provide an environment free from accident hazards and did not ensure adequate supervision to prevent accidents for a newly admitted resident. The resident, who had a history of smoking, multiple rib fractures, and falls, was admitted with these risk factors known to the facility. Despite this, the resident was able to access and use a personal lighter in their room while on oxygen therapy. This resulted in the resident accidentally igniting their oxygen tubing, causing a minor fire that damaged the floor and the oxygen concentrator. Surveyor observations confirmed physical evidence of the incident, including a discolored area on the floor and photographic documentation of burnt oxygen tubing and burn marks on the oxygen concentrator. Interviews with facility leadership revealed that the facility was aware of the resident's smoking history at admission but could not provide evidence that appropriate measures were taken to minimize accident hazards or provide adequate supervision. The resident confirmed using the lighter to find shoes in the dark, which led to the fire.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or inactions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Obtain Physician Order and Oversight at Admission
Penalty
Summary
A deficiency was identified when a resident was admitted without obtaining a doctor's order for admission and without ensuring the resident was under a physician's care. The required process to secure a physician's order and oversight at the time of admission was not followed, resulting in the resident not being under a doctor's care as mandated.
Failure to Follow Physician's Orders for PRN Medication Administration
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease and dependence on renal dialysis was admitted to the facility with a physician's order for Polyethylene Glycol 3350 (Miralax) to be administered as needed (PRN) for constipation, with instructions to hold for loose stools. Upon review, it was found that the order was incorrectly transcribed by an LPN as a daily medication rather than PRN, resulting in the resident receiving Miralax every morning from admission until the order was discontinued. The resident, who was cognitively intact, reported that they had never taken Miralax daily prior to admission and had not requested the medication to be changed to a daily order. Interviews with staff confirmed the transcription error, and there was no documentation to support that the physician's original PRN order had been changed to daily. The facility's leadership was unable to provide evidence that the medication was administered according to the physician's order during the specified period. The progress notes also did not indicate any provider-initiated change to the medication order upon admission.
Failure to Document Fluid Restriction and Administer Prescribed Medication for Dialysis Resident
Penalty
Summary
The facility failed to ensure that a resident with end stage renal disease and dependent on renal dialysis received care and services consistent with physician's orders and professional standards. Specifically, the resident had a physician's order for a 1000 ml daily fluid restriction, with detailed breakdowns for nursing and dietary fluid allowances, and required documentation of total fluid intake each shift. However, from 7/7/2025 to 7/17/2025, only nursing fluid intake was documented, and there was no evidence of total daily fluid intake being recorded. Staff interviews confirmed that intake and output were not documented, and the facility was unable to provide evidence that the fluid restriction was followed as ordered. Additionally, the resident had a physician's order for Sevelamer Carbonate 800 mg three times daily with meals to manage high blood phosphorus levels. On multiple dialysis days, the medication was not administered as ordered because the resident was absent from the facility for dialysis during scheduled administration times. The medication was not given after the resident returned, and there was no documentation that the provider was notified of the missed doses. Staff acknowledged the missed administrations and the lack of provider notification, and facility leadership could not provide evidence that the resident received the medication as ordered.
Resident Fall Due to Improperly Secured Mechanical Lift Sling
Penalty
Summary
A deficiency occurred when a resident with paraplegia, who required extensive assistance and the use of a mechanical lift for transfers, sustained a fall during a transfer from bed to wheelchair. The incident happened when staff were using a Hoyer lift and one of the sling straps slipped off or became unattached, causing the resident to fall from a height. The resident's leg struck the mechanical lift during the fall, resulting in a left femur fracture and a nondisplaced left sacral alar fracture, which required hospitalization and surgical intervention. Record reviews revealed that the resident was cognitively intact and dependent on two staff for transfers, as documented in the care plan and Minimum Data Set (MDS) assessment. The facility's policy on mechanical lifts required staff to securely attach sling straps according to the manufacturer's instructions and double-check their security before lifting the resident. However, staff interviews and progress notes confirmed that the sling was not properly secured, leading to the strap slipping off during the transfer. Both staff involved in the transfer and the resident confirmed that the fall occurred due to the strap becoming unattached while the resident was suspended in the lift. Further investigation showed that facility leadership, including the Director of Nursing Services (DNS) and the Administrator, were not present during the incident and could not provide evidence that the transfer was performed safely or that the resident was interviewed for a detailed account of the event. The lack of proper securing of the sling and failure to ensure adherence to established transfer protocols directly led to the resident's fall and subsequent injury.
Infection Control Deficiencies in PPE Compliance
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to required personal protective equipment (PPE) protocols for residents on droplet precautions. Resident ID #5, who was readmitted with end-stage renal disease and tested positive for Flu A, was observed by a surveyor when a nursing assistant entered the room without wearing the required gown, gloves, or eye protection, despite the posted signage indicating these precautions. Similarly, Resident ID #29, diagnosed with dementia and also positive for Flu A, had staff entering the room without proper PPE, including a certified medication technician who did not wear a gown, gloves, or eye protection. Further deficiencies were noted with Resident ID #106, who tested positive for COVID-19. Staff were observed entering the resident's room without eye protection, and one staff member exited the room without removing PPE, subsequently contaminating clean linens. Resident ID #107, also COVID-19 positive, had a hospice provider in the room without a gown or eye protection, unaware of the necessary precautions. These observations indicate a systemic issue with staff compliance to infection control protocols, as confirmed by interviews with staff and the infection preventionist. Additionally, the facility failed to adhere to enhanced barrier precautions for Resident ID #416, who had a PICC line due to osteomyelitis and gangrene. A licensed practical nurse was observed touching the PICC line dressing with ungloved hands, contrary to the posted precautions requiring gown and gloves during device care. This lapse was acknowledged by both the nurse involved and the Director of Nursing Services, highlighting a breach in infection control practices for residents with invasive devices.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an Infection Prevention and Control Program (IPCP) that includes an antibiotic stewardship program with protocols and a system to monitor antibiotic use. This deficiency was identified for three residents who were prescribed antibiotics without evidence of an antibiotic review or time-out. Resident ID #15 was readmitted with chronic obstructive pulmonary disorder and type II diabetes mellitus and was prescribed Levaquin for a cough. Resident ID #32, with chronic kidney disease and bipolar disorder, was prescribed Amoxicillin for a dental infection. Resident ID #53, diagnosed with Parkinson's disease and dementia, was prescribed Cephtriaxone for pneumonia. In all cases, there was no documentation of an antibiotic review or time-out. During an interview, the Infection Preventionist acknowledged that antibiotic time-outs were not completed for the residents receiving antibiotics. Furthermore, it was confirmed that the facility was not conducting antibiotic time-outs for any residents prescribed antibiotics. This lack of adherence to the CDC's recommended practices for antibiotic stewardship indicates a systemic issue in the facility's infection control program.
Improper PICC Line Dressing Change Procedure
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice concerning the care of a peripherally inserted central catheter (PICC line). The deficiency was identified during a surveyor observation where a resident with a PICC line had a dressing dated the same day, with gauze under the transparent dressing covering the insertion site. This setup made it difficult to assess for signs and symptoms of infection, which is contrary to the facility's policy and professional standards that require maintaining a sterile dressing for all peripheral catheter sites. During the observation, a Licensed Practical Nurse (LPN), identified as Staff A, was seen attempting to remove the PICC line dressing with soiled gloves, which she acknowledged was inappropriate. She also attempted to re-secure the dressing with ungloved hands, further breaching sterile procedure. Staff A admitted that changing a PICC line dressing is a sterile procedure and acknowledged her failure to maintain a sterile field or use sterile gloves. The Director of Nursing Services confirmed that Staff A's actions were incorrect, as she should not have attempted to remove the dressing with soiled gloves or without wearing gloves.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding the adherence to physician orders for wound care. Resident ID #79, who was readmitted to the facility with diagnoses including Alzheimer's disease and adult failure to thrive, was observed with a wound dressing on the back of the right hand that was visibly soiled and dated several days prior. The physician's order required daily cleansing and dressing of the wound, which was documented as completed on the Treatment Administration Record (TAR) for several consecutive days. However, during a surveyor observation, it was found that the dressing had not been changed as per the physician's order, as evidenced by the presence of dark, crusted drainage and an embedded dressing that required soaking for removal. Interviews with the LPN and the Director of Nursing Services confirmed that the treatment was not performed as documented, and the TAR should not have been signed off as completed. The Nurse Practitioner also expressed the expectation that the treatment should have been completed as ordered until the wound healed.
Failure to Timely Assess and Document Pressure Ulcer
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with a pressure ulcer, consistent with professional standards of practice. The resident, who was admitted with a pressure ulcer on the coccyx, did not have the wound measured or described upon admission. The initial assessment lacked details such as measurements, staging, exudate, pain, and the condition of the wound bed or edges. This lack of documentation persisted until a week after admission, when a Weekly Wound Progress Report finally recorded the wound's measurements. The resident was admitted with conditions including hemiparesis and hemiplegia, which increased the risk of pressure ulcer development due to immobility. The admission care plan identified the pressure ulcer as unstageable and included interventions for wound measurement and assessment. However, these interventions were not implemented in a timely manner, as evidenced by the absence of documentation until seven days post-admission. The Director of Nursing Services confirmed the lack of evidence for timely wound assessment during a surveyor interview.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, resulting in significant weight loss. The resident, who was readmitted to the facility with diagnoses including dementia and vitamin D deficiency, experienced severe weight loss over several months. The facility's policy required re-weighing the resident the next day for confirmation of any weight change of 5% or more, and notifying the dietician in writing if the weight was verified. However, the record review revealed that the resident was not re-weighed promptly after experiencing severe weight loss, and the dietician was not notified as required by the facility's policy. The resident's care plan included monitoring and reporting significant weight loss, but the facility failed to implement interventions after the resident experienced a severe weight loss of 19.5 lbs. (14.27%) from October 1, 2024, to January 9, 2025. The resident was last evaluated by the dietician on October 7, 2024, and had not been re-evaluated since the weight discrepancies were noted. Interviews with staff confirmed that the resident should have been re-weighed and that the dietician and provider should have been notified to implement interventions, but these actions were not taken.
Failure to Maintain Proper Bed Elevation During Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving continuous feeding via a gastrostomy tube (G-tube) was properly positioned to prevent complications such as aspiration. The resident, who was admitted with diagnoses including dysphagia and cognitive communication deficit, had a care plan in place to remain free from complications. A physician's order specified that the head of the resident's bed should be elevated to 30-45 degrees during feeding, flushing, and medication administration to prevent aspiration. During surveyor observations, it was noted that the resident's bed was not elevated to the required position while the enteral feeding was running. On two separate occasions, staff members, including a Speech Therapist and a Nursing Assistant, acknowledged the failure to maintain the correct bed elevation. The resident was observed coughing during one of these instances, indicating a potential risk of aspiration. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing Services, confirmed the requirement for bed elevation during feeding to prevent aspiration, highlighting the facility's failure to adhere to the prescribed care plan.
Failure to Maintain Accurate Medical Records for Wound Care
Penalty
Summary
The facility failed to maintain the medical record of a resident in accordance with accepted professional standards and practices. The resident, who was readmitted to the facility with diagnoses including Alzheimer's disease and adult failure to thrive, was observed with a wound dressing on the back of the right hand that was visibly soiled and dated several days prior. The physician's order required daily cleansing and dressing of the wound, but the Treatment Administration Record (TAR) indicated that the treatment was signed off as completed on multiple days by different LPNs, despite the dressing not being changed. Interviews with the involved staff revealed that the LPNs signed off on the wound treatment without actually performing it, and they were unaware of the dressing's date. The Director of Nursing Services confirmed that the TAR should not be signed off if the treatment was not completed. This discrepancy in record-keeping and treatment administration led to the deficiency being identified during the survey.
Medication Reconciliation Failure at Discharge
Penalty
Summary
The facility failed to properly reconcile medications for a resident being discharged, leading to a significant medication error. Resident ID #1, who had been admitted with serious health conditions including liver cell carcinoma and end-stage renal disease, was discharged with medications belonging to another resident, Resident ID #2. This error was discovered when a home care agency nurse reviewed the medications and found that Resident ID #1 had been given Atorvastatin, Lisinopril, and Amlodipine, which were prescribed for Resident ID #2. As a result, Resident ID #1 mistakenly took Atorvastatin on two separate occasions after discharge. The investigation revealed that the Licensed Practical Nurse involved in the discharge process did not verify the medications placed in the discharge bag and failed to provide medication instructions to Resident ID #1 or their family. The discharge paperwork also lacked any medication orders or instructions. The Director of Nursing Services could not explain why the medication reconciliation was not completed, nor why discharge instructions were not provided. This oversight placed residents at risk for serious harm, as noted in the report.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by not following a physician's orders for a resident. The resident, who was admitted with diagnoses including atrial fibrillation and pneumonia, had a physician's order to receive Cefpodoxime, an antibiotic, twice a day for three days. However, the medication was not administered as ordered on three occasions, specifically missing doses on two separate days. Interviews with staff revealed that the medication was available in the facility's automated dispensing system, yet it was not given to the resident. The nurse responsible for the resident on one of the days admitted to not administering the medication and failing to notify the provider of the missed doses. The Director of Nursing Services and the resident's physician were also unaware of the missed doses, indicating a breakdown in communication and adherence to medical orders within the facility.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure a safe environment for a resident at high risk for falls, resulting in a witnessed fall and subsequent injury. The resident, who was readmitted with a diagnosis including dementia, was assessed as requiring assistance from two staff members for bed mobility and turning. However, during an incident, only one Certified Nursing Assistant (NA) was present, and while providing care, the resident fell, sustaining head lacerations. The NA was unaware of the requirement for two staff members to assist the resident, as indicated in the resident's care plan and Kardex. Interviews with staff revealed discrepancies in the communication and understanding of the resident's care needs. The NA admitted to being unaware of the two-person assistance requirement, while a Licensed Practical Nurse (LPN) confirmed that the Kardex indicated the need for two staff members. The Director of Nursing Services acknowledged that the assessment tool and care plan were in error, leading to the misunderstanding of the resident's care requirements. This oversight resulted in inadequate supervision and a hazardous environment, contributing to the resident's fall and injuries.
Failure to Monitor and Record Catheter Care
Penalty
Summary
The facility failed to ensure that a resident with a suprapubic catheter received treatment and care in accordance with professional standards of practice. Resident ID #3, who was readmitted to the facility with diagnoses including urinary tract infection, anemia, and MRSA, had a care plan that required monitoring and recording of intake and output every 8 hours. However, the record review revealed no evidence that the facility was adhering to this standard. Additionally, the care plan required monitoring of urinary frequency, which was also not documented. During an interview, the Director of Nursing Services acknowledged the lack of monitoring and recording for this resident. Similarly, the facility did not provide appropriate care for Resident ID #4, who had a foley catheter and was readmitted with chronic kidney disease and dementia. The care plan for this resident also required monitoring and recording of intake and output every 8 hours, as well as monitoring urinary frequency. The record review showed no evidence of compliance with these requirements. During a surveyor interview, the Director of Nursing Services, along with the Administrator and Regional Nurse, could not explain why the facility failed to document the intake and output for both residents.
Failure to Notify Family of Hospital Transfer
Penalty
Summary
The facility failed to immediately inform the resident's representative about the decision to transfer a resident to an acute care hospital. The deficiency was identified during a review of a community-reported complaint submitted to the Rhode Island Department of Health. The complaint alleged that the resident was transferred to a hospital without notifying the family. The resident, who had been readmitted to the facility with diagnoses including urinary tract infection, anemia, and MRSA, was noted to have no urinary output and was complaining of abdominal pain. Consequently, the resident was sent to the hospital per the provider's order. However, there was no evidence in the nursing progress notes that the family was informed of this transfer. Further investigation revealed that the resident's daughter only learned of the hospital transfer during a conversation about the resident's positive MRSA test results, a day after the transfer. The resident's son was also not informed until five days later when contacted about holding the resident's bed. Interviews with staff, including the LPN who obtained the transfer order, failed to provide evidence that the family was notified at the time of the transfer. The LPN could not recall who was informed, and the Director of Nursing Services, Administrator, and Regional Nurse were unable to provide evidence of notification to the family.
Medication Error Leads to Hypotension in Resident
Penalty
Summary
The facility failed to ensure that all residents are free from significant medication errors, as evidenced by an incident involving a resident who received another resident's medications. The resident, admitted in August 2024 with diagnoses including pneumonia and abnormal weight loss, was mistakenly given their roommate's medications on 8/9/2024. This error was documented in a progress note and a Full QA Report, which indicated that the nurse did not perform the required five checks, leading to the administration of hydralazine 50 mg and labetalol 200 mg, both used to treat high blood pressure, to the wrong resident. As a result of this medication error, the resident experienced hypotension, or low blood pressure, although they remained asymptomatic. The incident was reported to the nurse practitioner, and new orders were issued to monitor the resident's blood pressure. The Director of Nursing Services acknowledged the error during a surveyor interview, confirming that the resident required intravenous fluids due to the low blood pressure caused by the medication error.
Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
The facility failed to provide written notice of the bed-hold policy to a resident or their representative prior to the resident's transfer to the hospital. The resident, who had been living in the facility for two years and had a diagnosis of Alzheimer's disease, was sent to the hospital due to aggressive behavior. Despite the resident's long-term stay, the facility informed the hospital case manager that the resident was considered short-term and that no beds were available upon the resident's discharge from the hospital. The facility did not respond to the hospital's attempts to coordinate the resident's return, and the resident's daughter was not informed of the bed-hold policy either verbally or in writing. Interviews with facility staff, including the DNS, Admissions Director, and Administrator, revealed a lack of communication and documentation regarding the bed-hold policy. The DNS admitted to not discussing the policy with the resident's daughter, and the Admissions Director acknowledged not providing the required written notice. The Administrator was unable to provide evidence of any written notice being given and was unaware of any contact made with the resident's daughter. Consequently, the resident's room was packed up, and the facility did not have a bed available for the resident's return.
Failure to Schedule and Facilitate Specialist Appointments
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not following physician orders for obtaining appointments with specialists. The resident, who was admitted in July 2024 with diagnoses including heart failure, end-stage renal disease, and diabetes, had several follow-up appointments scheduled, including a critical cardiology appointment. Despite the urgency, the facility did not arrange transportation for the resident to attend the cardiology appointment, and the resident missed it. The cardiology office attempted to contact the facility twice to reschedule, but no response was received. Additionally, a Nurse Practitioner had ordered follow-up appointments with hematology and a GI consult after reviewing the resident's critical BNP level, but there was no evidence that these appointments were scheduled. Interviews with the facility's staff, including the Director of Nursing Services, confirmed that the appointments were neither scheduled nor attempted to be scheduled, and no explanation was provided for the missed cardiology appointment. This lack of action resulted in the resident not receiving necessary specialist care as ordered.
Chemotherapy Dosage Error Due to Transcription and Review Failures
Penalty
Summary
The facility failed to provide accurate pharmaceutical services for a resident receiving chemotherapy medication. The resident, who was admitted with diagnoses including malignant neoplasm of the brain and bipolar disorder, was supposed to receive a daily dosage of 125 mg of Temozolomide. However, after being discharged from the hospital, the resident received only 5 mg daily from late July to early August, contrary to the prescribed 125 mg. This discrepancy arose because a Licensed Practical Nurse inaccurately transcribed the medication order as a taper instead of ensuring the total dosage equaled 125 mg. Additionally, the nurse did not reconcile the hospital's medication orders with the facility's Medication Administration Record (MAR) before the resident's hospitalization. The Pharmacy Consultant conducted a Medication Regimen Review on July 31 and failed to identify the discrepancy in the resident's chemotherapy medication dosage. During a surveyor interview, the Pharmacy Consultant acknowledged the oversight, admitting that the resident should have been on 125 mg of Temozolomide daily. This failure to identify and correct the medication error during the review process contributed to the resident not receiving the correct dosage of chemotherapy medication.
Medication Errors in Chemotherapy Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in administering the correct dosage and form of chemotherapy medication. The resident, who was admitted with diagnoses including malignant neoplasm of the brain and bipolar disorder, was supposed to receive Temozolomide at a dosage of 125 mg daily. However, due to an error in transcribing the medication order, the resident received only 5 mg daily for a period of time. This discrepancy was not identified because the Licensed Practical Nurse (LPN) did not reconcile the medication orders from the hospital with the facility's Medication Administration Record (MAR) upon the resident's readmission. The Director of Nursing Services (DNS) acknowledged the failure to follow the facility's policy for medication reconciliation. Additionally, the facility did not administer the chemotherapy medication in the correct form. The resident, who requires pureed food and crushed medications, was given Temozolomide capsules that were opened and administered contrary to the prescribing information, which states that the capsules should be swallowed whole. Both the Registered Nurse and the LPN involved confirmed that they administered the medication by opening the capsules, which was acknowledged as incorrect by the Nurse Practitioner. This practice was not aligned with the medication's prescribing guidelines, further contributing to the medication error.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an incident involving two residents that resulted in significant injury. Resident ID #1, who had intact cognition and required assistance for transfers and ambulation, was pushed by Resident ID #2, leading to a fall and a severe hip fracture. Resident ID #1 reported that Resident ID #2 entered their room, went through their belongings, and pushed them, causing the fall. This account was consistent with the observations of a Nursing Assistant who witnessed Resident ID #2 in Resident ID #1's room after hearing a loud thump. Resident ID #2, who had severe cognitive impairment due to Alzheimer's disease and dementia, had a history of disruptive and aggressive behaviors. The care plan for Resident ID #2 included interventions for managing these behaviors, such as redirection and monitoring. However, the facility did not effectively implement these interventions to prevent the altercation. Prior to the incident, Resident ID #2 had exhibited physical aggression towards staff and other residents, and the facility failed to provide sufficient protection to prevent resident-to-resident abuse. The facility's policy on abuse prevention emphasizes the protection of residents from abuse by anyone, including other residents. Despite this, the facility did not adequately assess the effectiveness of interventions for Resident ID #2's behaviors, nor did they provide immediate interventions to ensure the safety of other residents. The Director of Nursing Services acknowledged the lack of evidence that Resident ID #1 was kept free from abuse, highlighting a deficiency in the facility's ability to protect residents from harm.
Removal Plan
- The facility completed a Quality Assurance and Performance Improvement Plan to review the incident and identify areas of improvement.
- The facility completed an audit of current residents that exhibit aggressive behaviors, and they identified if the appropriate treatment is in place, that the provider is aware of the behaviors and that the family is in agreement with the plan of care.
- Education was provided to all staff on how to manage residents that exhibit aggressive behaviors.
- The perpetrator in this incident was placed on a 1:1 status. S/he will remain on a 1:1 until the interdisciplinary team reassesses the efficacy of the interventions.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure a resident's dignity was maintained for one of the residents reviewed. Nursing Assistant (NA), Staff A, allegedly called the resident a 'cripple' while providing care. The resident, who is cognitively intact with a Brief Interview for Mental Status score of 15 out of 15, reported feeling awful, angry, helpless, and degraded by the comment. The incident was corroborated by the resident's roommate and another NA, Staff B, who was present during the incident. Staff B also noted that the resident appeared visibly upset and requested not to be assisted by Staff A afterward. Despite the directive that Staff A should not be involved in the resident's care following the incident, there was evidence that Staff A entered the resident's room twice after the incident. The Director of Nursing Services was unable to provide evidence that Staff A was kept away from the resident's room as instructed. This failure to maintain the resident's dignity and adhere to the facility's policy on respectful communication constitutes a deficiency in care.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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