Riverview Healthcare Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Coventry, Rhode Island.
- Location
- 546 Main Street, Coventry, Rhode Island 02816
- CMS Provider Number
- 415082
- Inspections on file
- 39
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 13 (1 serious)
Citation history
Health deficiencies cited at Riverview Healthcare Community during CMS and state inspections, most recent first.
A resident with hypertensive heart disease and CHF had physician orders for Amlodipine and Spironolactone that required BP checks before administration, including a hold parameter for low systolic BP. The MAR, BP summary reports, and progress notes showed no documented BP readings before Amlodipine for 31 of 31 opportunities and before Spironolactone for 41 of 42 opportunities, and an LPN and the DON acknowledged the ordered monitoring was not completed.
Failure to provide enough food/fluids to maintain health occurred for a resident with dementia, dysphagia, anxiety, and right kidney cancer who had significant wt loss. An oncology consult recommended a high-protein supplement, but the record did not show it was implemented, and the RD said she was unaware of the recommendation while the NP said she expected the supplement would have been started.
Respiratory care was not provided consistent with professional standards for two residents. One resident with COPD and OSA had a CPAP order, but the record did not show that the mask, frame, and tubing were replaced per manufacturer guidelines, and the DON could not provide evidence of proper maintenance. Another resident with a tracheostomy and respiratory failure was observed receiving oxygen via trach without a documented physician order for the flow rate, and an LPN was unsure of the prescribed rate.
A resident with ESRD and gastritis had orders for dialysis and scheduled doses of Auryxia and Pentasa, but MAR review showed repeated missed 8:00 AM doses on dialysis days. The record did not show that the MD was notified, and the ADNS acknowledged Auryxia was not being given at the facility while the dialysis center confirmed it did not administer Pentasa during treatments.
Surveyors found multiple opened inhalers in medication carts that were not dated when opened, along with an expired inhaler that should have been discarded. They also observed an opened lorazepam liquid bottle without an open date, a vancomycin bottle kept past its discard date, a vaccine that should have been refrigerated but was not, and a nutritional supplement that required refrigeration after opening but was not stored on ice. Staff acknowledged several of these storage and labeling errors, and the DON, administrator, and regional leaders could not provide evidence that meds were being stored per accepted professional principles.
Failure to notify the provider and monitor a resident’s lower-extremity blister and edema. A resident with DM, hypertensive heart disease, and dementia was observed with a blister on the right shin, black scabs, and bilateral leg edema, but the record lacked evidence that the MD was notified or that treatments/interventions were in place. An LPN and the unit manager were unaware of the findings, and the DON could not show that the facility knew about the wound until surveyor attention brought it to light.
The facility did not provide enough nursing staff during an overnight shift, leaving only one NA and one nurse to care for 24 residents on a unit. Two residents with significant care needs, including frequent falls, incontinence, and pressure ulcers, did not receive the required level of care and monitoring. Staff and management interviews confirmed that the staffing was below the facility's own minimum requirements and was insufficient to meet residents' needs.
A resident experiencing severe respiratory distress was emergently transferred to a hospital with another resident's identifiers and medical record due to an LPN's error. The resident received care under the wrong identity for several hours, and the hospital contacted the wrong representative for consent for intubation. The DON confirmed the error and the resident's history of respiratory compromise.
The facility did not ensure consistent and comprehensive care plans for two residents with complex transfer and fall prevention needs. Documentation across care plans, Kardex, physician orders, SPH evaluations, and NA assignments contained conflicting information about required transfer assistance, leading to confusion among staff. Interviews with LPNs, NAs, and the DON confirmed that transfer instructions were not consistently communicated or documented.
A resident with multiple chronic conditions experienced a significant change in condition and was transferred to the hospital, but the facility failed to notify the correct physician and the resident's representative. Instead, an LPN contacted the provider for a different resident and did not inform the appropriate parties, resulting in incorrect documentation and confusion for the resident's family.
A resident with severe respiratory and cardiac conditions was transferred to the hospital with another resident's medical record and identifiers after an LPN misidentified the patient and failed to follow protocol for reporting a change in condition. The hospital treated the resident under the wrong information for several hours, and the DON could not provide evidence of the LPN's competency with acute condition protocols.
The facility failed to maintain safe water temperatures, with readings exceeding the maximum allowable limit on all floors. A resident reported the water was hot enough to cause skin reddening, confirmed by surveyors. Despite recorded temperatures exceeding limits, no corrective action was documented, and the facility could not provide evidence of ensuring a hazard-free environment.
The facility was cited for deficiencies in food safety standards. Two staff members in the main kitchen were observed without beard restraints while handling food, violating the Rhode Island Food Code. Additionally, an ice machine lacked the required air gap, as confirmed by the Director of Maintenance and the Food Service Director.
The facility failed to ensure a functioning call light communication system, leading to long wait times for residents needing assistance. Staff interviews and observations revealed that call lights did not alert staff directly or through a centralized system, as walkie talkies were no longer in use.
The facility failed to follow physician orders and care plans for several residents, including improper wound care, lack of documentation for glucose monitoring, and incorrect application of therapeutic devices. Observations revealed non-compliance with prescribed treatments, such as wound dressing changes, hand splint usage, and hot pack application, highlighting deficiencies in adhering to professional standards of practice.
The facility failed to implement contact precautions for residents with MDROs, as staff members entered rooms without wearing gowns and gloves despite clear signage. Residents with MRSA and ESBL were affected, and staff interviews revealed misunderstandings about precaution requirements. The Infection Preventionist and facility leadership confirmed the expectation for staff to follow these precautions.
A facility failed to provide a resident with a smoking apron as required by their care plan, leading to cigarette ashes landing on their clothing. Despite the care plan indicating the need for a smoking apron, staff were unaware of when it should be applied, and there was no documentation of the resident's refusal to use it.
The facility failed to prevent significant medication errors involving Coumadin administration for multiple residents. Errors included incorrect transcription of orders, missed doses, and incorrect dosing, leading to elevated INR levels and potential health risks. Staff acknowledged these errors during surveyor interviews.
A resident with a Stage 2 pressure injury developed a new Stage 1 pressure injury on the right heel. Despite identification by an LPN, there was no evidence of provider notification or treatment implementation. Weekly skin checks noted the injury, but no further description or treatment orders were documented. The DON was unaware of the injury, leading to a deficiency in pressure ulcer care and prevention.
A resident with a history of traumatic brain injury and anxiety, diagnosed with Influenza A, did not receive appropriate oxygen therapy due to an incorrectly transcribed physician's order. The resident experienced a fall and distress with fluctuating oxygen saturation levels, leading to a hospital transfer and diagnosis of acute respiratory failure and pyothorax. Staff interviews revealed a lack of awareness of the resident's oxygen needs and the transcription error.
A resident's medical record was inaccurately documented, indicating an open area on the coccyx that did not exist. This error was acknowledged by the RN who completed the assessment, and the DON confirmed the inaccuracy but could not explain it. The deficiency was identified during a surveyor interview and record review.
A resident with congestive heart failure, type 2 diabetes, and major depressive disorder had a physician's order for daily weights, but the facility failed to obtain the resident's weight on multiple occasions and did not report a significant weight gain to the provider. The resident denied refusing to be weighed, and the primary nurse admitted to documenting refusals when the resident was asleep. The Nurse Practitioner was unaware of the weight gain, indicating a communication breakdown within the facility.
Failure to Follow BP Monitoring Orders for Medications
Penalty
Summary
The facility failed to follow physician's orders for Resident ID #17 by not obtaining and documenting blood pressure readings before administering medications that required monitoring parameters. The resident was admitted with diagnoses including hypertensive heart disease and congestive heart failure. Physician's orders included Amlodipine 5 mg in the morning with instructions to monitor blood pressure prior to administration, and Spironolactone 25 mg, one-half tablet twice daily, with instructions to hold the medication if systolic blood pressure was less than 110 mmHg. Review of the MAR showed no documented blood pressure readings before Amlodipine administration for 31 of 31 opportunities between 3/1/2026 and 3/31/2026. The MAR also showed no documented blood pressure readings before Spironolactone administration for 41 of 42 opportunities between 3/10/2026 and 3/31/2026. Blood pressure summary reports and progress notes also did not show evidence that blood pressure monitoring was performed as ordered. During interview, the LPN was unable to provide evidence that blood pressures were obtained per the physician's orders, and the DON acknowledged that the blood pressures should have been obtained before administration of the medications.
Failure to Implement Recommended High-Protein Supplement
Penalty
Summary
Provide enough food and fluids to maintain a resident's health was not ensured for Resident ID #8, who had diagnoses including dementia, dysphagia, anxiety, and cancer of the right kidney. The resident weighed 147.0 lbs. on 3/1/2026 and 121.8 lbs. on 3/30/2026, reflecting a 12.89% weight loss. An oncology consultation and referral form dated 3/10/2026 recommended a high-protein dietary supplement, and an APRN progress note dated 3/18/2026 stated the recommendation was being referred to the dietician. However, the record did not show that the high-protein supplement was implemented. During interview, the RD stated she was unaware of the oncologist's recommendation, and the NP stated she referred the choice of supplement to the dietician and was not aware it had not been implemented, though she expected it would have been.
Respiratory Care Not Provided Consistent With Standards
Penalty
Summary
Respiratory care was not provided consistent with professional standards for a resident using CPAP. The resident was admitted with diagnoses including chronic obstructive pulmonary disease and obstructive sleep apnea, and had a physician’s order to apply CPAP at bedtime. Facility records did not show that the CPAP mask, frame, and tubing were being replaced according to the manufacturer’s replacement guidelines, which called for specific replacement intervals for those parts. During interview, the Director of Nursing Services was unable to provide evidence that the CPAP was maintained per the manufacturer’s guidelines. Respiratory care was also not provided consistent with professional standards for a resident with a tracheostomy. The resident was readmitted with diagnoses including acute and chronic respiratory failure and tracheostomy status, but the clinical record did not show a physician’s order for the intended oxygen flow rate to be administered via the tracheostomy. During observation, the resident was receiving oxygen at 5 LPM via tracheostomy, and an LPN stated she was unsure of the resident’s prescribed oxygen flow rate. A progress note later documented that the nurse notified the provider about the missing order, and an order was obtained for oxygen at 4 LPM via tracheostomy. The DON was unable to provide evidence that the resident received respiratory care consistent with professional standards related to oxygen administration.
Missed Dialysis-Day Medication Doses
Penalty
Summary
The facility failed to ensure that a resident receiving dialysis remained free from significant medication errors. The resident was readmitted in January 2026 with diagnoses including end stage renal disease and gastritis, and had a physician order for outpatient dialysis every Monday, Wednesday, and Friday with pickup at 5:45 AM. The resident also had orders for Auryxia 1 gram, 3 tablets by mouth before meals at 8:00 AM, 11:00 AM, and 4:00 PM, and Pentasa 500 mg, 2 capsules three times daily at 8:00 AM, 12:00 PM, and 4:00 PM. Review of the 2026 MAR showed no evidence that the resident received the 8:00 AM dose of Auryxia on multiple dialysis days, and no evidence that the resident received the 8:00 AM dose of Pentasa on multiple dialysis days. The record also failed to show that the physician was notified when these doses were missed. During interview, the ADNS acknowledged that the 8:00 AM Auryxia was not being administered at the facility on dialysis days, and stated that Pentasa was being given at the outpatient dialysis center; however, the dialysis center Clinical Manager stated that the center does not administer Pentasa during treatments. The physician stated he was unaware the medications were not being administered as ordered and said he would have adjusted the administration times if informed.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles in multiple medication carts and medication rooms. Surveyors observed several opened inhalers on the East Wing B side medication cart, the A side medication cart, the 2 East medication cart, and the 2nd floor South medication cart that were not labeled with the date opened, including Advair Diskus, Incruse Ellipta, Trelegy Ellipta, and Bretzi AeroSphere inhalers. One Trelegy Ellipta inhaler was labeled with an open date and expiration date, but another Trelegy Ellipta inhaler and a Bretzi AeroSphere inhaler were not dated. Staff acknowledged that the inhalers should have been dated when opened, and one expired inhaler should have been discarded. Surveyors also found a bottle of vancomycin labeled to discard after a specified date that remained in storage, and an opened bottle of lorazepam liquid that was not dated when opened. Additional observations in the first floor A side medication cart found a Prevnar 20PF vaccine labeled to refrigerate that was not refrigerated, and a Med Plus 2.0 nutritional supplement that required refrigeration after opening and discard after three days but was not being stored on ice. Staff acknowledged the vaccine should have been refrigerated and was unsure whether the supplement should have been on ice despite the manufacturer label. In the first floor East Unit medication room and the 2nd floor medication room, opened lorazepam liquid bottles were observed without dates when opened, and staff acknowledged the dating requirement. The Director of Nursing Services, Regional Director of Operations, Administrator, and Regional Director of Clinical Services were unable to provide evidence that medications were being stored in accordance with accepted professional principles, including expiration dates.
Failure to Notify Provider and Monitor Lower Extremity Blister and Edema
Penalty
Summary
The facility failed to ensure that staff provided treatment and care in accordance with professional standards of practice for a resident with diagnoses including type 2 diabetes, hypertensive heart disease, and dementia. The resident required extensive assistance with toileting hygiene, dressing, and footwear. A care plan had a focus area for potential skin breakdown, and later a focus area was initiated to monitor and document edema and report abnormal findings to the physician. During surveyor observations, the resident was seen with a blister on the right lower shin surrounded by small black scabs and with notable edema in both legs. The record did not show that the physician was notified of the blister or the edema, and it also lacked evidence of treatments or interventions being in place. When the resident was observed with the blister and bilateral edema, an LPN acknowledged the findings but stated she was unaware of them. The unit manager also stated she was unaware of the blister and said the provider should be notified of any change in condition. A later progress note documented an intact blister on the right shin measuring 3.56 cm by 4.21 cm, and the DON was unable to provide evidence that the provider had been notified or that the facility was aware of the wound until it was brought to their attention by the surveyor.
Insufficient Overnight Staffing Resulting in Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff on the One East Unit during the overnight shift, resulting in only one nursing assistant (NA) and one nurse being present to care for 24 residents. This staffing level was below the facility's own minimum requirement of one nurse and two NAs for the unit. Staff interviews confirmed that management was aware of the unsafe staffing situation, and the Assistant Director of Nursing Services acknowledged that staffing with less than two NAs would not be safe, especially for residents requiring lifts for transfers. Record review showed that only nine NAs worked in the facility that night, which was below the required minimum for all units combined. Two residents on the unit were directly affected by the staffing shortage. One resident, admitted with dementia, lack of coordination, and a history of falls, required maximum assistance with toileting, hygiene, and transfers using a mechanical lift, as well as frequent checks to prevent skin breakdown. This resident experienced multiple falls during their admission. Another resident, admitted with a history of stroke and schizoaffective disorder, was incontinent, required maximum assistance with hygiene, had impaired mobility, and had a stage two pressure ulcer requiring repositioning at least every two hours. This resident also experienced multiple falls and required 15-minute safety checks. Staff interviews indicated that the single NA on duty was unable to complete more than one round of care for each resident due to insufficient staffing.
Failure to Provide Accurate Resident Identification During Emergency Transfer
Penalty
Summary
The facility failed to ensure accurate and appropriate information was communicated to the receiving health care provider during an emergent discharge. When a resident experienced a significant change in condition requiring emergency transfer to an acute care facility, an LPN incorrectly identified the resident and sent the individual to the hospital with another resident's identifiers and medical record. As a result, the resident was registered at the hospital under the wrong name and date of birth, and medical care was provided under the incorrect identity for approximately two hours. The error was discovered when the hospital contacted the facility to clarify the resident's identity. Record review showed that the resident who was actually transferred had a history of chronic obstructive pulmonary disease and congestive heart failure and was in severe respiratory distress at the time of transfer, requiring intubation. The incorrect medical record and identifiers were provided to EMS, and the resident was unable to correct the information due to decreased consciousness. The Director of Nursing Services confirmed that the wrong medical record was sent and acknowledged the resident's history of respiratory compromise. The incident resulted in the resident's representative not being contacted for consent for intubation, as the hospital had contacted the wrong representative based on the incorrect identifiers.
Failure to Implement Consistent, Comprehensive Care Plans for Safe Transfers
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for two residents with identified needs for safe transferring and fall prevention. For one resident with type II diabetes and chronic kidney disease, there were multiple conflicting interventions documented regarding transfer assistance, including discrepancies between the care plan, Kardex, physician orders, Safe Patient Handling (SPH) evaluations, and nursing assistant (NA) assignments. These inconsistencies ranged from requiring a mechanical lift with two staff, to a stand and pivot transfer with a gait belt, to a one-person assist, with no evidence of consistent communication or documentation to ensure safe transfers. Staff interviews confirmed the lack of alignment and clarity in transfer instructions across different documentation sources. For another resident with type II diabetes and muscle weakness, similar inconsistencies were found. The care plan, Kardex, physician orders, SPH evaluation, and NA assignments all contained differing information regarding the resident's transfer and ambulation needs, ranging from supervision with a walker to requiring a mechanical lift with two staff. Staff interviews acknowledged that the SPH status was not consistently reflected across all forms of communication and documentation, and that the information should be uniform to ensure safe care. These findings were based on record reviews, staff interviews, and a community complaint alleging frequent patient falls and safety risks.
Failure to Notify Physician and Representative of Resident Change in Condition
Penalty
Summary
The facility failed to immediately notify the appropriate physician and the resident's representative when a resident experienced a significant change in condition and required emergency transfer to the hospital. Specifically, a resident with chronic obstructive pulmonary disease and congestive heart failure was found to have altered mental status, shortness of breath, excessive sputum, and was unable to follow commands. Emergency Medical Services were called, and the resident was transferred to the hospital, where they required intensive care and intubation. However, the facility contacted the on-call provider for a different resident and did not notify the correct physician or the resident's representative about the change in condition or the hospital transfer. Record review and staff interviews confirmed that the progress notes and physician orders were incorrectly documented for another resident, not the one who was actually experiencing the emergency. The resident's representative was not informed of the transfer, and the hospital was given incorrect patient identifiers. The Director of Nursing and the Administrator were unable to provide evidence that the correct notifications were made as required. The deficiency was identified through review of records, interviews with staff and resident representatives, and cross-referenced with related deficiencies.
Failure to Ensure Nursing Staff Competency During Emergency Transfer
Penalty
Summary
Licensed nursing staff failed to demonstrate the necessary competencies and skills to meet resident needs during an emergency transfer. Specifically, an LPN incorrectly identified a resident experiencing a significant change in condition and reported the wrong resident to the on-call provider. The LPN also sent the incorrect medical record and patient identifiers with the resident during transfer to the hospital, resulting in the hospital treating the resident under another individual's information for approximately two hours. The facility's policy required nursing staff to collect and organize pertinent information and accurately report the resident's current symptoms and status to the physician, which was not followed in this instance. The resident involved had a history of chronic obstructive pulmonary disease and congestive heart failure and was admitted to the hospital's Intensive Care Unit requiring intubation after presenting with altered mental status, excessive sputum, and cool skin. The LPN did not provide a verbal report to the hospital at the time of transfer, and the Director of Nursing Services was unable to provide evidence that the LPN was competent with the facility's protocol for acute condition changes. This series of actions and omissions resulted in the resident being at risk for delayed or inappropriate treatment.
Unsafe Water Temperatures in Facility
Penalty
Summary
The facility failed to maintain safe water temperatures, resulting in an environment that was not free from accident hazards. During a survey, it was observed that water temperatures on all three floors of the facility exceeded the maximum allowable limit of 118 degrees Fahrenheit, as per state regulations. Specific instances included water temperatures reaching up to 125.1 degrees Fahrenheit, which was confirmed through both resident interviews and direct measurement by surveyors. A resident reported that the water was hot enough to cause reddening of the skin, and this was corroborated by the surveyor's observation. The facility's records indicated that water temperatures had been recorded as exceeding 120 degrees Fahrenheit on multiple occasions, yet there was no evidence that these findings were reported or corrected according to the facility's policy. The Regional Maintenance Director acknowledged the issue, attributing it to a potential problem with the mixing valve, but no corrective action was documented. The Administrator and Director of Nursing Services were unable to provide evidence that the facility had taken steps to ensure the resident environment was free of accident hazards, as required by regulations.
Deficiencies in Food Safety Standards
Penalty
Summary
The facility was found to have deficiencies in food service safety standards during a survey. Specifically, two staff members in the main kitchen, a Dietary Aide and a Cook, were observed with full facial hair and were not wearing beard restraints while handling food. This is a violation of the Rhode Island Food Code 2018 Edition, which requires food employees to wear hair and beard restraints to prevent hair from contacting exposed food. The Food Service Director acknowledged this oversight during an interview with the surveyor. Additionally, an ice machine on the first floor was observed to lack an air gap, which is a requirement under the Rhode Island Food Code 2018 Edition. The code mandates that an air gap between the water supply inlet and the flood level rim of the plumbing fixture must be at least twice the diameter of the water supply inlet and not less than 25 millimeters. The Director of Maintenance and the Food Service Director confirmed the absence of the required air gap during the surveyor's observation.
Deficiency in Call Light Communication System
Penalty
Summary
The facility was found to be inadequately equipped to allow residents to call for staff assistance through a communication system that relays the call directly to a staff member or a centralized staff work area. During a resident council task, multiple residents complained about long wait times for their call lights to be answered, attributing this to the staff no longer carrying walkie talkies. Surveyor observations across all units revealed that not all resident rooms' call lights were visible from the nurse's station, and the call lights did not relay calls directly to staff members or a centralized staff work area. Interviews with various staff members, including LPNs and NAs, confirmed that the call lights previously communicated with walkie talkies carried by Nursing Assistants, but these devices were no longer in use. Staff members acknowledged that the only indication of an engaged call light was the light above the resident's door, with no centralized alert system in place. The facility's Administrator also confirmed that the call lights did not communicate directly to staff or a centralized location, contributing to the deficiency in responding promptly to residents' needs.
Deficiencies in Adhering to Physician Orders and Care Plans
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for several residents. For Resident ID #77, who was readmitted with MRSA and type 2 diabetes, the facility did not adhere to the physician's order to change the wound dressing on the resident's left foot twice daily. The dressing was not changed on multiple occasions, and during an observation, the dressing was found with dried drainage, indicating neglect in following the prescribed treatment plan. Resident ID #33, in a persistent vegetative state, had a stage 4 pressure ulcer on the coccyx. The physician's order required a 5-minute soak with vashe, but during an observation, the soak was only performed for approximately 2 minutes. Additionally, the resident was not wearing hand splints as ordered, with multiple observations confirming their absence. Staff interviews revealed a lack of awareness and adherence to the care plan. For Resident ID #20, the use of a Freestyle Libre sensor for glucose monitoring was not documented in the physician's orders or care plan, indicating a lack of oversight in managing the resident's diabetes care. Furthermore, Resident ID #103 had a hot pack applied for back pain, but it was left on for two hours instead of the prescribed 15 minutes. Staff interviews confirmed a lack of knowledge regarding the correct duration for the hot pack application.
Failure to Implement Contact Precautions for Residents with MDROs
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding the implementation of contact precautions for residents with Multidrug Resistant Organisms (MDROs). Four residents, identified as having conditions such as Methicillin Resistant Staphylococcus Aureus (MRSA) and Extended-spectrum beta-lactamases (ESBL), were observed to be on contact precautions. However, staff members repeatedly entered these residents' rooms without adhering to the required precautions of wearing gowns and gloves, as indicated by the signage posted outside the rooms. For Resident ID #77, who had MRSA in wounds on their feet, a Nursing Assistant entered the room without the necessary protective equipment. Similarly, for Resident ID #153, who had MRSA in their urine, a Licensed Practical Nurse also failed to wear a gown and gloves upon room entry. These actions were contrary to the facility's policy and the posted instructions, which were acknowledged by the staff during interviews. Resident ID #330, diagnosed with ESBL, had multiple staff members, including maintenance staff, an occupational therapist, and an activity aide, enter their room without the required protective gear. Additionally, Resident ID #332, with MRSA in their nares, had a Certified Occupational Therapy Assistant enter their room without a gown or gloves. Interviews with the staff revealed misunderstandings about the necessity of wearing protective equipment upon room entry, despite clear signage and facility expectations. The Infection Preventionist, Director of Nursing Services, and the Administrator all confirmed that staff should adhere to these precautions.
Failure to Provide Assistive Devices for Safe Smoking
Penalty
Summary
The facility failed to ensure that a resident was provided with assistive devices to prevent accidents related to smoking. The resident, who was admitted in April 2023 with diagnoses including traumatic brain injury, schizoaffective disorder, and epilepsy, was observed smoking without a smoking apron, contrary to the facility's policy and the resident's care plan. The care plan indicated that the resident could smoke safely with a smoking apron, but it did not specify when the apron should be applied. During the observation, ashes from the resident's cigarette were seen landing on their pajama pants. Staff interviews revealed a lack of awareness regarding the specific circumstances under which the resident should wear a smoking apron. The Registered Nurse present during the observation acknowledged the absence of the apron and the falling ashes. The Assistant Director of Nursing confirmed that the resident's smoking assessment required the use of a smoking apron. The Director of Nursing Services also acknowledged the requirement but noted that the resident sometimes refused to wear the apron, although no documentation of such refusals was available.
Significant Medication Errors with Coumadin Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, particularly concerning the administration of Coumadin, an anticoagulant medication. For Resident ID #1, despite a physician's order to hold Coumadin due to an elevated INR, the medication was administered, leading to a critically high INR and an unwitnessed fall. The Director of Nursing Services acknowledged the failure to transcribe the order to hold the medication, and the Registered Nurse Practitioner was unaware of the administration error. Resident ID #4 experienced a missed dose of Coumadin due to a transcription error, which resulted in the medication not being administered as scheduled. Additionally, the INR order was not transcribed, leading to a delay in monitoring the resident's blood clotting levels. The Licensed Practical Nurse could not explain the omission, indicating a lapse in the facility's medication administration process. Other residents, including Resident IDs #5, #6, #7, #8, and #9, also experienced medication errors due to transcription mistakes and missed doses. These errors included incorrect start and stop dates for Coumadin administration, leading to missed doses and incorrect dosing. The facility's staff, including Registered Nurse Practitioners and Licensed Practical Nurses, acknowledged the transcription errors and the resulting significant medication errors during surveyor interviews.
Failure to Provide Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide necessary treatment and services to promote wound healing and prevent new pressure ulcers from developing for a resident with existing pressure ulcers. The resident was admitted with a Stage 2 pressure injury to the buttocks and later developed a Stage 1 pressure injury on the right heel. Despite the identification of the new pressure injury by a Licensed Practical Nurse (LPN), there was no evidence that the provider was notified or that a treatment plan was implemented for the new injury. The weekly skin checks documented the presence of the pressure injury on the resident's right heel, but there was no further description or treatment order documented. The Director of Nursing Services was unaware of the pressure injury and could not provide evidence of any treatment being implemented when the injury was first identified. This lack of action and communication led to the deficiency in providing appropriate pressure ulcer care and prevention measures for the resident.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care to a resident who required oxygen therapy, as evidenced by the incorrect transcription of a physician's order. The resident, who had a history of traumatic brain injury and anxiety, was diagnosed with Influenza A and required oxygen therapy to maintain oxygen saturation levels above 91%. However, the order for oxygen therapy was incorrectly transcribed to start and end on the same day, leading to a lack of active orders for continued oxygen therapy. On the day following the incorrect transcription, the resident experienced a fall and was found in distress with an oxygen saturation level of 86%. Despite being placed back on oxygen and receiving a nebulizer treatment, the resident's oxygen saturation only increased to 90%. The resident refused transfer to a hospital after EMS was called. Throughout the day, the resident's oxygen saturation levels fluctuated, and it was unclear whether the resident was consistently receiving oxygen therapy as required. The situation escalated when the resident's oxygen saturation dropped to 80% on 2 liters of oxygen, leading to a call to 911 and the resident's transfer to an acute care hospital. The resident was diagnosed with acute respiratory failure and later with pyothorax, requiring intubation and transfer to a trauma hospital. Interviews with staff revealed a lack of awareness regarding the resident's oxygen needs and the incorrect transcription of the oxygen order, contributing to the deficiency in care.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, leading to a deficiency in safeguarding resident-identifiable information. The resident, who was admitted in October 2023 with diagnoses including traumatic brain injury and anxiety, was inaccurately documented as having an open area on the coccyx during a weekly skin assessment. This error was acknowledged by the Registered Nurse, Staff E, who completed the assessment and admitted to documenting the open area in error. The Director of Nursing Services confirmed the inaccuracy but was unable to explain why the resident's medical record was incorrect. This deficiency was identified during a surveyor interview and record review, highlighting a lapse in maintaining medical records in accordance with accepted professional standards.
Failure to Monitor and Report Resident's Weight
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for a resident with diagnoses including congestive heart failure, type 2 diabetes mellitus, and major depressive disorder. The resident had a physician's order for daily weights with specific instructions to report significant weight changes. However, the resident's weight was not obtained on 8 out of 18 opportunities, and it was documented as refused on 5 occasions. The resident denied refusing to be weighed, and the primary nurse admitted to documenting refusals when the resident was asleep. Additionally, a significant weight gain of 9.2 pounds over four days was not reported to the provider, and no interventions were implemented for this weight gain. Interviews with the resident, nursing staff, and the Director of Nursing Services revealed that the nurses did not follow the physician's order, and the provider was not notified of the weight gain or missed weights. The Nurse Practitioner was unaware of the resident's non-compliance and the significant weight gain, indicating a communication breakdown within the facility. The Director of Nursing Services acknowledged that the nurses should have followed the physician's order and reported the weight gain to the provider.
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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