The Dawn Hill Home For Rehab And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Bristol, Rhode Island.
- Location
- One Dawn Hill Road, Bristol, Rhode Island 02809
- CMS Provider Number
- 415050
- Inspections on file
- 43
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at The Dawn Hill Home For Rehab And Healthcare during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease receiving hospice services was observed by an RN to be grimacing, with swelling and bruising of the right ankle, and an x-ray later confirmed displaced fractures of the medial and lateral malleolus. Facility policy required that responsible family or legal representatives be notified within 24 hours of significant condition changes or injuries and that this notification be documented in the medical record. A NP documented the fracture findings and ordered that hospice and the resident’s representative be contacted, but there was no documentation that the representative was notified. In interviews, the resident’s representative reported learning of the injuries from hospice staff, the RN acknowledged not notifying the representative, and the DON could not provide evidence that immediate notification occurred, resulting in a deficiency for failure to notify the representative of a significant change in condition.
A resident with Alzheimer's disease, severe cognitive impairment, and non-ambulatory status, receiving hospice care, was found grimacing with swelling and bruising to the right ankle after being brought to the dining room. An x-ray later confirmed acute to subacute displaced fractures of both the medial and lateral malleolus, with no cause identified in the record, making it an injury of unknown origin. A hospice aide reported that during care, the resident became agitated and flailed while two CNAs held the resident's arms and legs, but care was not stopped and the nurse was not notified of the behavior. The RN on duty could not show that the injury of unknown origin was reported to RIDOH, and the DON acknowledged that the incident was not reported, resulting in a failure to report an alleged violation and injury of unknown origin as required.
A non-ambulatory hospice resident with severe cognitive impairment developed swelling and bruising of the right ankle after being taken to the dining room and receiving care in the room, during which the resident became agitated and flailed while a hospice aide and two CNAs continued care and physically held the resident’s arms and legs. An RN later noted the ankle changes, obtained an x-ray order from a provider, and imaging confirmed acute to subacute displaced fractures of both the medial and lateral malleolus. The clinical record and interviews with the RN, DON, and NP showed that no thorough investigation was conducted into the origin of the injury, no potential causes were documented or identified, and no interventions to prevent further or potential injury were documented, despite regulatory requirements and a community complaint alleging lack of notification and unclear cause of the injury.
A resident with dementia and a documented tomato allergy consumed food with red tomato sauce and was subsequently ordered a one-time dose of Reglan 10 mg by a provider, with instructions for close monitoring for allergic reaction. The MAR showed the Reglan entry coded to refer to progress notes, where an LPN documented that the medication was pending pharmacy delivery, but there was no evidence that the dose was ever administered or that the provider was notified of the omission. A Pyxis inventory showed Reglan was routinely stocked, and in interviews the LPN confirmed the medication was not given and the DON stated she would have expected the medication to be administered as ordered and the provider notified and documentation completed if it was not.
A resident with dementia had a tomato allergy documented in the EHR, yet was served food containing red tomato sauce despite this known allergy. A progress note recorded that the resident consumed the tomato sauce and required close monitoring for signs and symptoms of an allergic reaction. The DON later acknowledged in an interview that the resident had a documented tomato allergy and should not have been served a tomato product, and the issue came to light after a community complaint alleging the resident experienced an acute medical episode due to an allergic reaction.
Two residents with hypertension received Hydralazine despite physician orders specifying administration only above certain systolic blood pressure thresholds. Medication records showed the drug was given multiple times when blood pressure was below the ordered limits, and LPNs confirmed these errors during surveyor interviews. The DON could not provide evidence that the residents were free from unnecessary medications.
A resident admitted after back surgery did not receive adequate pain management due to the facility's failure to administer the correct dosage of oxycodone for severe pain, as indicated in the hospital's COC form. Additionally, the facility did not administer Decadron, a prescribed steroid, due to a lack of transcription and communication with the provider. This resulted in the resident being transferred back to the hospital for pain management.
A resident admitted after back surgery did not receive prescribed medications due to unavailability and lack of staff communication with the provider. Despite protocols, staff failed to utilize available resources like the Pyxis machine and did not notify the provider about missed doses. The facility's Regional DON and NP expected adherence to medication orders and communication, which was not met.
A newly admitted resident who underwent back surgery was transferred back to the hospital due to the facility's failure to have prescribed medications available. The facility did not accurately maintain the resident's medical records, missing orders for Decadron and incorrect dosage for oxycodone. The Regional DON acknowledged the oversight but could not provide evidence of accurate record maintenance.
A resident with an ileostomy experienced inadequate care due to the facility's failure to provide the correct size ostomy supplies, leading to leakage and redness around the stoma. Staff interviews confirmed that the available appliance did not fit properly, causing stool to leak into a surgical wound. The resident was transferred to the hospital after family concerns about the care provided.
The facility failed to properly label and store medications in two medication storage rooms. In the North Medication Storage Room, a vial of Tuberculin was found opened and undated, contrary to manufacturer instructions. Similarly, in the East Medication Storage Room, a bottle of Ativan Intensol was opened and undated. Both LPNs present acknowledged the oversight, and the DON confirmed the expectation for medications to be dated upon opening.
A facility failed to maintain professional standards in administering IV antibiotics via a PICC line and in medication administration for residents. An LPN did not assess for blood return or scrub the needleless connector before reconnecting IV tubing for a resident with bacteremia. Additionally, a medication technician administered whole tablets instead of crushed ones to a resident with dysphagia, contrary to special instructions.
A resident with a Suprapubic Catheter (SPC) was not provided appropriate catheter care as per the care plan, which required the catheter bag to be maintained below bladder level to prevent CAUTI. Surveyors observed the catheter bag lying on the mattress next to the resident, and staff interviews confirmed the failure to adhere to the care plan.
A facility failed to maintain accurate medical records for a resident with urinary retention, resulting in conflicting catheter size orders. Staff interviews revealed the current catheter size was 18 Fr, but the order for 16 Fr was not discontinued. Additionally, another resident's advance directives were mistakenly uploaded, conflicting with the resident's Do Not Resuscitate and No Artificial Nutrition orders. The DON acknowledged these discrepancies.
A resident with intact cognition was unable to reach their call bell, which had fallen to the ground, leading them to yell for help due to pain for half an hour. The facility's policy requires call bells to be within reach, but this was not adhered to, as confirmed by a nursing assistant and the DON.
The facility failed to follow physician orders for daily weight monitoring for two residents with cardiac conditions. Weights were not obtained on multiple occasions, and there was no notification to the MD or NP about these omissions. Staff interviews revealed a lack of awareness about the need to report missed weights, and the DON expected weights to be obtained and reported if not.
A resident with a history of CHF and A-fib was readmitted to an LTC facility but did not receive prescribed medications for 16 days due to incomplete admission orders. The admitting nurse transcribed orders from a document listing pre-admission medications instead of obtaining the correct discharge summary. This oversight led to the resident's return to the hospital with difficulty breathing, and the hospital contacted the facility about the missed discharge orders.
A resident receiving hospice care was found in bed covered in dried blood and feces, as reported by the family to the Rhode Island Department of Health. The resident, with a history of joint implant, diabetes, and congestive heart failure, was initially thought to be covered in feces by staff, but it was later identified as blood. The Director of Nursing Services could not provide evidence that the resident was checked on at the start of the shift.
A resident with type 2 diabetes did not receive prescribed Humalog insulin for four days due to unavailability. Staff interviews revealed a lack of communication with the pharmacy and provider. The DON confirmed the facility had an insulin emergency kit, but no actions were taken to address the unavailability.
A facility failed to maintain accurate medical records for a resident on hospice care. The resident's Ativan order was discontinued, yet Health Status Notes incorrectly indicated its use. The Nurse Practitioner acknowledged the error, and the DON expected a review of current medications during visits.
A facility failed to maintain proper hospice documentation for a resident receiving hospice care. Despite a physician's order and a hospice plan of care, the necessary Hospice Recommendation forms were missing from the facility's records. Interviews with hospice staff confirmed that the forms were provided, but they were not found in the resident's hospice binder, indicating a lapse in maintaining complete records.
A resident with dementia pushed another resident with Alzheimer's, resulting in a dislocated shoulder. The incident was witnessed by a staff member, but the facility failed to provide evidence of measures taken to prevent such abuse, highlighting a deficiency in protecting residents from harm.
Failure to Notify Resident Representative of Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s representative of a significant change in condition, specifically an injury of unknown origin resulting in right ankle fractures. The facility’s policy dated 10/19/2023 requires responsible family members or legal representatives to be notified as soon as possible, or within 24 hours, of any changes in the resident’s condition, including significant physical changes and any accidents resulting in injury, with documentation of such notification in the medical record. The resident, admitted in October 2025 with Alzheimer’s disease and receiving hospice services, was observed on 3/9/2026 by an RN to be grimacing after being brought to the dining room, and further assessment revealed swelling and bruising of the right ankle. An x-ray was ordered and later confirmed acute to subacute fractures of the medial malleolus with displacement and a moderately displaced fracture of the lateral malleolus. A subsequent progress note by a nurse practitioner documented the fracture findings and included an order to contact hospice and the resident’s representative to review the results. However, record review did not show any evidence that the resident’s representative was notified by the facility of the injuries, nor was there documentation of such notification in the medical record as required by policy. During interviews, the resident’s representative stated that they were not notified by the facility and instead learned of the injuries from hospice staff. The RN who first identified the bruising and swelling acknowledged that she did not notify the resident’s representative. The Director of Nursing Services was unable to provide evidence that the resident’s representative was immediately notified when the injuries were identified, confirming the failure to follow the facility’s notification policy.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
The facility failed to timely report an injury of unknown origin to the Rhode Island Department of Health (RIDOH) for a resident with Alzheimer's disease who was non-ambulatory, dependent on staff for all transfers, and had severe cognitive impairment. The resident, who was on hospice services, was brought to the dining room by staff and was later observed grimacing, with swelling and bruising to the right ankle. An x-ray obtained that evening confirmed acute to subacute fractures of both the medial and lateral malleolus with displacement. A subsequent nurse practitioner note documented the fracture findings and included an order to contact hospice and the resident's representative, but the clinical record did not identify a cause for the injury, classifying it as an injury of unknown origin. Record review also failed to show that this injury of unknown origin was reported to RIDOH. During interviews, a hospice aide reported that after lunch she provided care to the resident in the room, accompanied by two CNAs. She stated the resident was not in discomfort before care, but became agitated during care and flailed upper and lower extremities, while one CNA held the resident's legs and another held the resident's arms; she did not stop care or notify the nurse of the resident's behavior. After care, the resident was transferred to a chair and returned to the dining room, and the aide later learned of the swollen ankle after returning from lunch, without knowing how the injury occurred. The RN on duty at the time of injury identification was unable to provide evidence that the injury of unknown origin was reported to RIDOH, and the Director of Nursing Services acknowledged that the facility did not report the injury to RIDOH, confirming the failure to report the alleged violation and injury of unknown origin as required.
Failure to Investigate Injury of Unknown Origin and Identify Cause of Ankle Fractures
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an injury of unknown origin for a non-ambulatory resident with Alzheimer’s disease who was dependent on staff for all transfers and had severe cognitive impairment. The resident, who was on hospice services, was brought to the dining room by staff and later exhibited grimacing, with swelling and bruising noted to the right ankle. An x-ray obtained the same day confirmed acute to subacute displaced fractures of both the medial and lateral malleolus. Although the nurse on duty notified the provider and obtained the x-ray order, the clinical record lacked documentation of any investigation into how the injury occurred, any determination or discussion of potential causes, or identification of the origin of the fractures. Surveyor interviews revealed that a hospice aide, accompanied by two CNAs, had taken the resident to the room after lunch to provide care. During care, the resident, who had not shown discomfort beforehand, became agitated and flailed upper and lower extremities while one CNA held the resident’s legs and another held the resident’s arms; care was continued despite the agitation, and the nurse on duty was not notified of this behavior. After care, the resident was transferred to a chair and returned to the dining room, and the hospice aide later learned of the swollen ankle but did not know how the injury occurred. The RN who discovered the swelling and bruising, the DON, and the NP all acknowledged there was no thorough investigation, no documentation establishing the origin of the injuries, and no evidence of implemented measures to prevent further or potential injury, and the facility could not provide investigative findings or evidence of required reporting.
Failure to Administer Ordered Medication After Known Food Allergy Exposure
Penalty
Summary
The facility failed to ensure services were provided in accordance with professional standards of quality by not following a physician’s order for a resident who had a known tomato allergy. The resident, admitted with dementia and with a documented tomato allergy of unknown severity in the electronic health record since June 2025, consumed food containing red tomato sauce. A nurse practitioner documented that the resident had eaten red tomato sauce despite the allergy and ordered a one-time dose of Reglan 10 mg with continued close monitoring for any signs and symptoms of allergic reaction. A corresponding physician’s order for Reglan 10 mg once was entered on the same date. Review of the Medication Administration Record for that month showed Reglan coded as “9” by an LPN, indicating to refer to progress notes. A progress note by the same LPN documented that the Reglan was pending delivery from the pharmacy, and there was no evidence in the record that the medication was ever administered or that the provider was notified that the ordered medication was not given. An inventory summary for the facility’s Pyxis automated dispensing machine showed that it routinely stocked at least three 5 mg Reglan tablets. In an interview, the LPN acknowledged that the Reglan was not administered and could not provide evidence of provider notification, and the Director of Nursing stated that Reglan is regularly stocked in the Pyxis and that she would have expected the medication to be administered as ordered and the provider notified and documentation completed if it was not.
Failure to Prevent Serving Allergen-Containing Food to Resident With Documented Tomato Allergy
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with a documented tomato allergy was not served tomato products. The resident, admitted in July 2024 with dementia, had an allergy to tomatoes recorded in the electronic health record as of 6/24/2025, with the severity listed as unknown. Despite this documented allergy, a progress note by the Nurse Practitioner dated 10/9/2025 at 10:30 AM states that the resident was noted to have eaten red tomato sauce in their food that afternoon, which they are allergic to, and that the resident required continued close monitoring for any signs and symptoms of allergic reaction. During a surveyor interview on 2/5/2026, the Director of Nursing Services acknowledged that the resident had a documented tomato allergy and should not have been served a tomato product. The deficiency was identified following a community-reported complaint submitted to the Rhode Island Department of Health on 1/27/2026 alleging that the resident experienced an acute medical episode as a result of an allergic reaction. The survey findings, based on clinical record review and staff interview, confirmed that the facility served food containing tomato sauce to the resident despite the known allergy documented in the resident’s record.
Failure to Prevent Administration of Unnecessary Antihypertensive Medications
Penalty
Summary
The facility failed to ensure that two residents' drug regimens were free from unnecessary drugs, specifically regarding the administration of antihypertensive medication. For one resident with a diagnosis of essential hypertension, a physician's order specified that Hydralazine 50 mg should be administered only if the systolic blood pressure (SBP) was greater than 160. However, medication administration records showed that the resident received Hydralazine multiple times when their SBP was below 160, with readings as low as 117. This was acknowledged by an LPN during a surveyor interview, confirming that the medication was given contrary to the physician's order. Another resident, also diagnosed with essential hypertension, had a physician's order for Hydralazine 25 mg every six hours, to be held if the SBP was less than 110. Despite this, records indicated that the medication was administered on several occasions when the resident's SBP was below 110, with readings as low as 88. This was similarly acknowledged by another LPN. The Director of Nursing Services was unable to provide evidence that these residents were free from unnecessary medications, as required.
Inadequate Pain Management and Medication Oversight
Penalty
Summary
The facility failed to provide adequate pain management for a resident who was admitted after undergoing extensive back surgery. Upon admission, the resident was supposed to receive oxycodone for pain management as per the hospital's Continuity of Care (COC) form, which indicated a dosage of one to two tablets every four hours as needed. However, the facility only administered one tablet of 5 mg oxycodone, even when the resident's pain was severe, reaching 8 out of 10 and 9 out of 10 on the pain scale. The facility did not have an order for the two-tablet dosage, which was necessary for severe pain, leading to the resident being transferred back to the hospital for pain management. Additionally, the facility failed to administer Decadron, a steroid medication prescribed to treat inflammation, as indicated in the hospital COC form. The medication was not transcribed or addressed with the provider, and the resident did not receive the scheduled dose. The oversight was acknowledged by the Regional Director of Nursing Services, who noted that the Decadron order was not listed in one section of the COC document but was present on another page. The Nurse Practitioner involved did not recall being informed about the Decadron order, contributing to the deficiency in the resident's care.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the lack of administration of prescribed medications upon admission. The resident, who had undergone extensive back surgery, was admitted to the facility with multiple diagnoses including fusion of the spine, radiculopathy, type II diabetes, high blood pressure, GERD, and hyperlipidemia. Despite having physician's orders for several medications, including Atorvastatin, Calcium Carbonate, Carvedilol, Polyethylene Glycol, Metformin, and Senna-Docusate Sodium, the resident did not receive these medications at the scheduled time on the day of admission. The report highlights that the facility's staff did not follow the established protocol for obtaining medications when they were unavailable. The Registered Nurse interviewed stated that she would check the Pyxis machine and notify the provider if a medication was unavailable, but there was no evidence that the provider was informed about the missed medication administrations. Additionally, the Registered Pharmacist confirmed that some of the medications were available in the Pyxis machine and others were available as facility stock, indicating a failure in the medication administration process. Further deficiencies were noted when a physician's order for Mounjaro, a medication for diabetes, was not administered as it was unavailable. The Licensed Practical Nurse responsible for administering the medication did not notify the resident's provider about the unavailability, which was acknowledged during a surveyor interview. The Regional Director of Nursing Services and the Nurse Practitioner both expressed expectations that the staff should have ensured the resident received the medications as ordered and communicated any issues to the provider, which did not occur in this instance.
Failure to Maintain Accurate Medical Records for Newly Admitted Resident
Penalty
Summary
The facility failed to accurately maintain the medical record of a newly admitted resident who had undergone extensive back surgery. Upon admission, the facility did not have the resident's medications available, leading to the resident being transferred back to the hospital for pain management on the same day. The resident's neurosurgeon had prescribed Decadron, a steroid medication, but the facility was unaware of this prescription. The resident was admitted with diagnoses including fusion of the spine and radiculopathy. A review of the hospital's Continuity of Care (COC) document indicated that the resident was to receive oxycodone for pain management, with a specific dosage that was not accurately reflected in the facility's records. Additionally, the COC form showed that the resident was to receive Decadron at a specific time, but there was no evidence in the facility's records that this medication was administered or addressed with the provider. During an interview, the Regional Director of Nursing Services acknowledged that the staff should have addressed the medication orders with the provider and documented the interaction, but was unable to provide evidence that the facility maintained accurate medical records.
Inadequate Ostomy Care Due to Incorrect Supplies
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice for a resident with an ileostomy. The resident was admitted with an ileostomy and had a mid-abdominal wound and surgical wounds on the left lower abdomen. A complaint was submitted to the Rhode Island Department of Health alleging inadequate ostomy care. The facility's policy on colostomy and ileostomy care required proper application and documentation of ostomy appliances, but the facility did not have the correct supplies for the resident. The resident's family requested a hospital transfer due to concerns about ostomy and wound care, and the hospital confirmed that the ostomy appliance was not adhered properly, leading to stool leakage into a surgical wound. Interviews with facility staff revealed that the ostomy wafer did not adhere to the resident's skin, and the available appliance was not the correct size. Staff acknowledged redness and leakage around the peristomal area. The wound nurse confirmed that the wafer was leaking and had ordered a smaller size, but it was not available in time to prevent leakage. The Director of Nursing Services admitted that the resident did not receive the appropriate size ostomy supplies, resulting in fecal leakage into the abdominal wound.
Failure to Properly Label and Store Medications
Penalty
Summary
The facility failed to adhere to professional standards for labeling and storing drugs and biologicals in two of the three medication storage rooms observed. During a surveyor observation in the North Medication Storage Room, a vial of Tuberculin Purified Protein Derivative was found opened and undated. The Licensed Practical Nurse (LPN) present, Staff E, acknowledged the oversight and confirmed that the vial should have been dated upon opening. The manufacturer's instructions specified that the vial should be discarded 30 days after opening. In a separate observation in the East Medication Storage Room, a bottle of Ativan Intensol was also found opened and undated. LPN Staff F confirmed that the bottle should have been dated when opened. The instructions on the bottle indicated it should be discarded 90 days after opening. The Director of Nursing Services later confirmed that she expected all medication bottles to be dated once opened and acknowledged that both the Ativan Intensol and Tuberculin should be discarded.
Deficiencies in IV and Medication Administration Practices
Penalty
Summary
The facility failed to maintain professional standards of practice in the administration of intravenous (IV) antibiotics via a peripherally inserted central catheter (PICC) line for a resident diagnosed with bacteremia. During an observation, a Licensed Practical Nurse (LPN) did not assess for blood return before administering ampicillin intravenously, which is necessary to ensure the patency of the PICC line. Additionally, the LPN disconnected the IV tubing due to an infusion pump alarm and failed to scrub the needleless connector on the resident's catheter before reconnecting the IV tubing. Both the LPN and the Director of Nursing Services acknowledged these lapses in protocol during interviews. The facility also failed to adhere to medication administration instructions for a resident with dysphagia, who was supposed to receive medications in crushed form. A Certified Medication Technician administered whole tablets of Seroquel with cranberry juice, contrary to the special instructions to crush the medication. This deviation from the prescribed method of administration was acknowledged by the technician and the Director of Nursing Services during interviews.
Failure to Maintain Proper Catheter Care for Resident with SPC
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with a Suprapubic Catheter (SPC). The resident was admitted with a diagnosis of obstructive and reflux uropathy. According to the care plan and physician's orders, catheter care was to be provided every shift, and the catheter bag was to be maintained below the bladder level to prevent backflow of urine, which could increase the risk of catheter-associated urinary tract infections (CAUTI). However, during surveyor observations, the catheter bag was repeatedly found lying flat on the mattress next to the resident, contrary to the care plan instructions. Surveyor interviews with the resident and staff revealed a lack of adherence to the care plan. The resident was unaware of who placed the catheter bag on the mattress. Nursing Assistants and an LPN acknowledged the catheter bag should have been placed lower than the bladder level. The Assistant Director of Nursing Services also confirmed the improper placement of the catheter bag and stated that staff were expected to maintain it below the bladder level as per the care plan.
Inaccurate Medical Records and Advance Directives Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with urinary retention, as evidenced by conflicting physician orders regarding the size of the urinary catheter. The resident's physician order list contained multiple orders with different catheter sizes and balloon volumes, leading to confusion about the correct size to be used. During interviews, staff revealed that the resident's current catheter size was 18 Fr, and the order for 16 Fr should have been discontinued. This inconsistency in documentation indicates a lack of adherence to accepted professional standards for maintaining medical records. Additionally, the facility failed to accurately document the resident's advance directives. The resident was documented as having a Do Not Resuscitate order and No Artificial Nutrition directive. However, another resident's advance directives, indicating a Full Code Status and the administration of artificial nutrition via a feeding tube, were mistakenly uploaded into the resident's records. This error was acknowledged by the Director of Nursing Services, who confirmed the discrepancies in the resident's medical records regarding both the catheter orders and advance directives.
Deficiency in Call System Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a working call system was available and within reach for a resident, leading to a deficiency in providing adequate means for the resident to call for assistance. The policy titled Call Bell Policy requires staff to ensure the resident's safety by keeping the call bell within reach. However, during a surveyor observation, a resident was found yelling for help due to pain for half an hour because the call bell had fallen to the ground and was not accessible. The resident, who had intact cognition as indicated by a Brief Interview for Mental Status score of 15 out of 15, confirmed that the call bell was out of reach. A nursing assistant acknowledged the issue, and the Director of Nursing Services stated that the call bell should have been within the resident's reach.
Failure to Follow Physician Orders for Weight Monitoring
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by not following physician orders for obtaining daily weights for two residents. Resident ID #1, admitted with atherosclerotic heart disease and congestive heart failure, had a physician's order for daily weight monitoring to manage their condition. However, the daily weights were not obtained on several specified dates, and there was no evidence that the physician or nurse practitioner was notified of the missed weights. Similarly, Resident ID #2, who was admitted with congestive heart failure and supraventricular tachycardia, also had a physician's order for daily weight monitoring. The facility failed to obtain the resident's weights on multiple dates across November and December, and there was no documentation indicating that the physician or nurse practitioner was informed of these omissions. Interviews with staff revealed a lack of awareness regarding the necessity to report the inability to obtain weights, and the Director of Nursing Services expressed an expectation that weights should be obtained as ordered and reported if not.
Failure to Administer Prescribed Medications Upon Readmission
Penalty
Summary
The facility failed to obtain complete admission orders for a resident's immediate care upon readmission from the hospital, resulting in the resident not receiving prescribed medications. The resident, who had a history of congestive heart failure and persistent atrial fibrillation, was readmitted to the facility from the hospital but did not receive the necessary medications, including amiodarone, Anora Ellipta, and furosemide, for 16 days. This oversight occurred because the admitting nurse transcribed medication orders from a document listing medications prior to the hospital admission, rather than obtaining the correct discharge summary or continuity of care form. The deficiency was identified following a community-reported complaint to the Rhode Island Department of Health, which alleged that the resident was not administered the prescribed amiodarone upon readmission, leading to a return to the hospital. The facility's records lacked evidence of a hospital discharge summary or physician's orders for the medications dated on the day of readmission. Interviews with staff, including the Unit Manager and the Director of Nursing Services, confirmed that the correct discharge documents were not obtained, and the resident's medication orders were inaccurately transcribed from the wrong document. The resident was eventually transferred back to the hospital due to difficulty breathing, where it was confirmed that the missed medications contributed to the resident's condition. The hospital contacted the nursing facility regarding the missed discharge orders, highlighting the failure to administer the prescribed medications. The resident's physician expressed an expectation that the nurse should have contacted the hospital to request the correct continuity of care form and follow the instructions provided.
Resident Found in Bed with Dried Blood and Feces
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as evidenced by an incident where the resident was found in bed covered in a large amount of dried blood and feces. The resident, who had been readmitted to the facility with diagnoses including a joint implant, diabetes mellitus, and congestive heart failure, was receiving hospice care. A complaint was submitted to the Rhode Island Department of Health after the resident's family discovered the condition on October 6, 2024. A photograph accompanying the complaint showed the resident lying in bed with dark brown matter, which appeared to be dry and cracking, on both legs, the bed sheet, and the shirt. Interviews with staff revealed that a Licensed Practical Nurse (LPN) and two nursing assistants (NAs) were involved in cleaning the resident. Initially, the substance was thought to be feces, but during a shower, the LPN realized it was blood. The Director of Nursing Services indicated that NAs typically check on residents at the start of the shift, around dinner time, and around 10:00 PM, but there was no evidence that the resident was checked on at the start of the shift. The resident passed away on October 7, 2024, and was unable to be interviewed.
Failure to Administer Insulin Due to Unavailability
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of insulin. The resident, who was readmitted to the facility in September 2024 with conditions including type 2 diabetes mellitus and was receiving hospice care, had a physician's order for Humalog insulin to be administered at bedtime. However, the Medication Administration Record showed that the resident did not receive the prescribed insulin on four consecutive days, as it was documented as unavailable. There was no evidence that the provider was notified about the unavailability of the insulin during this period. Interviews with staff revealed a lack of communication and follow-up regarding the unavailability of the medication. A Licensed Practical Nurse admitted to not remembering if she contacted the pharmacy or the provider about the missing insulin. The Nurse Practitioner was unaware of the situation and stated that she would have expected the nurse to notify both the pharmacy and the provider. The Director of Nursing Services confirmed that the facility had an insulin emergency kit and that the order could have been adjusted if the Humalog kwikpen was unavailable, but there was no evidence of any such actions being taken.
Failure to Maintain Accurate Medication Records for Hospice Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was readmitted in September 2024 with conditions including a joint implant, diabetes mellitus, and congestive heart failure, and was receiving hospice care. The deficiency was identified during a record review which revealed discrepancies in the documentation of the resident's medication orders. Specifically, Health Status Notes written by a Nurse Practitioner on 9/30/2024 and 10/4/2024 indicated that the resident was to use Ativan for anxiety as part of hospice care, despite the fact that the Ativan order had been discontinued on 9/13/2024 and was not reordered until 10/6/2024. During interviews conducted by the surveyor, the Nurse Practitioner acknowledged the expectation that the resident would be on Ativan due to hospice care, but confirmed that there was no active order for the medication at the time of her notes. The Director of Nursing Services also stated that she would expect the Nurse Practitioner to review the resident's current medications during her visits. This oversight in maintaining accurate and complete medical records for the resident led to the identified deficiency.
Deficiency in Hospice Documentation for Resident
Penalty
Summary
The facility failed to ensure that hospice services met professional standards for a resident receiving hospice care. A physician's order was placed for a hospice evaluation and admission, and the resident began receiving hospice care shortly thereafter. The hospice plan of care indicated that the resident would be seen by a nurse multiple times a week initially, and then weekly for the following weeks. However, the facility did not have the necessary Hospice Recommendation forms on file, which are crucial for communicating recommendations and assessments made by hospice nurses. Interviews with hospice staff revealed that the resident was seen by hospice nurses on specific dates, but the required documentation was missing from the facility's records. The hospice nurse who saw the resident the day before their passing confirmed that she provided the necessary form to the facility, but it was not found in the resident's hospice binder. The Nurse Practitioner and the Director of Nursing Services both expressed expectations that the hospice documentation should be complete and available for review, highlighting the deficiency in maintaining proper records for hospice care provided to the resident.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving two residents. Resident ID #2, who has a history of dementia and other mental health issues, pushed Resident ID #1 into a precaution bin, causing Resident ID #1 to fall and sustain a dislocated left shoulder. This incident was witnessed by a Nursing Assistant, Staff A, and reported to the Rhode Island Department of Health. The facility's internal investigation confirmed the incident, but the facility was unable to provide evidence that Resident ID #1 was kept free from abuse. Resident ID #1, who has Alzheimer's Disease and anxiety, was admitted to the facility in March 2021 and has a BIMS score indicating impaired cognition. Resident ID #2, admitted in March 2022, also has impaired cognition with a BIMS score of 7 out of 15. Despite the presence of cognitive impairments in both residents, the facility did not evaluate the effectiveness of interventions or provide immediate measures to ensure the safety of residents, leading to the failure to prevent resident-to-resident abuse.
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The facility failed to follow physician orders for post-fall care for three anticoagulated residents who experienced falls. One resident on a blood thinner with a head injury was ordered to be transferred to the ED after a telehealth evaluation, but an LPN did not send the resident, citing instructions to contact a supervisor first and inability to reach that supervisor. For two other residents on anticoagulants, providers ordered intensive neuro checks (every 15 minutes, then every 30 minutes, then hourly, then every 4 hours), but staff instead performed neuro checks only once per shift for 72 hours. The DON and Medical Director acknowledged that the transfer and monitoring orders were not implemented as written.
A resident with intact cognition and psychiatric diagnoses sustained a left eyebrow laceration when another resident with a documented history of escalating aggressive and threatening behaviors struck them with a cane during a hallway dispute. The aggressive resident had multiple prior documented incidents, including verbal threats to kill others, attacking a roommate with a cane over TV volume, throwing objects during activities, and throwing a lunch plate at staff. Despite these events, the care plan was not updated with interventions to address physical aggression toward other residents, and a psychiatric recommendation for PRN trazodone for agitation, anxiety, and insomnia was only implemented as PRN for insomnia. The failure to assess, monitor, and implement effective interventions for the aggressive resident’s behaviors led to the assault and injury and, per the report, placed this and other residents at risk of serious physical and psychosocial harm.
A resident with impulse disorder, mood and anxiety diagnoses, and a history of escalating verbal and physical aggression had multiple documented incidents of threats, object throwing, and assault with a cane. Despite a psychiatric consult recommending PRN trazodone for agitation, anxiety, and insomnia, the provider order listed insomnia only, and the care plan was not updated with specific interventions to address the resident’s physically aggressive behaviors after several documented events. Subsequently, the resident struck another resident with a cane, causing a facial laceration that required wound closure and ongoing treatment.
The facility failed to properly screen and document clearance for a NA with disqualifying criminal history information before hire, as required by its abuse, neglect, and exploitation policy. A BCI check showed disqualifying information, yet the NA was hired, completed orientation, and worked independently based only on verbal disclosure of an old drug-related charge, without written details or verification. Later, a staff member reported witnessing this NA grab a resident’s face and kiss the resident on the lips, and a community complaint alleged inappropriate interactions with the same resident, prompting involvement of local police.
A resident with anxiety disorder and PTSD was unable to attend meals and activities with peers because the facility lost the resident's clothing after it was sent to laundry. The resident was observed in a hospital gown with only a few clothing items in the room, and the record lacked an admission inventory of belongings. The DON/Administrator reported that laundry was handled by an outside vendor without a tracking system or item documentation.
A resident with dementia and severely impaired cognition was subjected to repeated non-consensual kissing on the lips by an NA, who entered the resident’s room during care, verbally expressed affection, and then kissed the resident on the mouth on at least two separate occasions witnessed by staff. One staff member delayed reporting the first incident due to fear of the NA. These actions occurred despite a facility policy defining sexual abuse as any non-consensual sexual act and requiring protections of residents’ rights and well-being.
Failure to investigate allegations of resident-to-resident sexual inappropriateness: A resident with dementia and TBI was documented as being inappropriate with another resident, and psych notes later described increased sexually inappropriate behaviors toward other residents. Staff interviews showed the resident had been observed touching others and needing frequent redirection, but the DON, ADON, and Administrator acknowledged the facility did not complete an investigation or recognize the allegation as possible abuse.
A resident with dementia and a hearing deficit did not receive ear care as ordered because the chart lacked the Debrox order and the ear was flushed before the intended Debrox course was completed. In a separate incident, staff witnessed inappropriate kissing of a resident with dementia, but the allegation was not reported to the provider and the care plan was not updated. A third resident’s wound care was also not completed as ordered when an RN used normal saline instead of the prescribed Vashe wound wash.
A resident with migraines and chronic pain did not receive timely pain management after repeatedly reporting a migraine and appearing in visible distress. An NA notified an LPN, an RN said she could not access the med cart, and the resident continued waiting while the LPN was off the unit; the PRN migraine medication was not given until 40 minutes after the first complaint. The DON acknowledged the resident should not have waited that long for pain medication.
A resident missed 6 doses of a prescribed antibiotic, and the MAR did not show that the provider was notified. The RN acknowledged the missed doses and said they should have been reported, while the Medical Director stated she was unaware of the missed doses and would have extended the antibiotic course if informed. The DON also confirmed the missed doses and expected provider notification for any missed antibiotic dose.
Failure to Follow Post-Fall Physician Orders for Anticoagulated Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement physician orders for post-fall care, including hospital transfer and neurological monitoring, for residents on anticoagulant therapy. One resident with atrial fibrillation on Xarelto experienced an unwitnessed fall with a scalp laceration and head lump. The on-call provider, after a telehealth evaluation, ordered transfer to the ED and wrote an order directing that the resident be sent to the hospital. The resident was not transferred as ordered, and an additional order for vital signs and neuro checks every shift for 72 hours after the fall was not completed as ordered on one of the shifts. The LPN caring for this resident stated she did not send the resident to the ED because she had been instructed to call a supervisor before sending residents out, and she was unable to reach the supervisor during the shift. A second resident, also with atrial fibrillation and on Xarelto, had an unwitnessed fall with injury. The on-call provider was notified and ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, then every four hours for an additional 24 hours. A physician’s order reflecting this schedule was scanned into the EMR. However, the neuro checks were not completed as ordered; instead, they were performed only once per shift for 72 hours. The RN who authored the progress note documented the fall and the resident’s anticoagulant use, and later stated she could not remember why she did not transcribe and complete the neuro checks as ordered. A third resident with atrial fibrillation on Apixaban had a non-injury fall after attempting to walk independently. The on-call provider ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, and then every four hours for an additional 24 hours, and this order was scanned into the EMR. The record did not show that these neuro checks were completed as ordered; instead, neuro checks were documented only once per shift for 72 hours. The Medical Director stated he would have expected the first resident to be transferred to the ED as ordered and that the facility should not override a provider’s order. The DON acknowledged that the transfer order and the ordered monitoring for the first resident were not followed as written, and that for the second and third residents, staff performed only once-per-shift neuro checks instead of the more frequent monitoring ordered by the providers.
Failure to Manage Escalating Aggression Leading to Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident, Resident ID #1, from abuse by another resident with a known history of escalating aggression, Resident ID #2. Resident ID #1 was admitted in October 2025 with diagnoses including paranoid schizophrenia and adjustment disorder with mixed anxiety and depressed mood, and had a BIMS score of 14/15, indicating intact cognition. On 4/27/2026, progress notes documented that Resident ID #1 was on the receiving end of a physical altercation with another resident and was found with a deep bleeding abrasion to the left eyebrow. A subsequent nursing note described a new laceration to the left eyebrow measuring 0.5 cm by 2.0 cm by 0.1 cm, related to a resident-to-resident incident, for which wound closure strips were applied. Resident ID #1 requested police involvement and a police report, and refused transfer to the hospital for sutures. Resident ID #2 had been admitted in December 2024 with multiple psychiatric and behavioral diagnoses, including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed a BIMS score of 13/15 and documented both physical and verbal behaviors during the look-back period. Progress notes over several months recorded a pattern of escalating aggressive and threatening behaviors: on 9/13/2025, Resident ID #2 threatened to slit another resident’s throat and made additional threats toward staff; on 11/7/2025, the resident was involved in a verbal dispute with raised voice, name-calling, and verbal threats; on 12/28/2025, after another resident struck Resident ID #2 with a helmet, Resident ID #2 was overheard threatening to kill that resident if touched again. On 2/21/2026, the on-call provider documented that Resident ID #2 attacked a roommate with a cane over TV volume and required ER transfer for psychiatric evaluation. Subsequent notes on 3/9/2026 and 4/10/2026 described the resident throwing poker chips on the floor, yelling and swearing at staff and residents, and throwing a lunch plate across the nurses’ station at a nursing assistant due to dissatisfaction with portion size. Despite this documented pattern, the care plan for Resident ID #2, dated 1/16/2025, only indicated a behavior problem of being verbally aggressive toward staff with resident-to-resident altercations on 12/28/2025, 2/21/2026, and 4/27/2026, and record review failed to show added interventions to mitigate the risk of physical aggression toward other residents after the 2/21/2026 cane attack and the object-throwing incidents on 3/9/2026 and 4/10/2026. A psychiatric evaluation on 4/23/2026 recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order entered on 4/24/2026 specified trazodone 25 mg twice daily as needed only for insomnia, and record review did not show that agitation and anxiety were included as indications for use. During interviews, the RNP and the DON stated it was their expectation that agitation and anxiety would have been included in the trazodone order, and the DON was unable to provide evidence that the care plan had been updated with interventions to address Resident ID #2’s physically aggressive behaviors documented on 2/21/2026, 3/9/2026, and 4/10/2026. On 4/27/2026, the DON documented that Resident ID #2 was ambulating down the hall toward his/her room while Resident ID #1 was walking in the opposite direction, and the two residents began a verbal dispute. Before staff could intervene, Resident ID #2 used his/her cane to make contact with Resident ID #1, resulting in the eyebrow laceration that required steri-strips and ongoing wound treatment. A police incident report recorded that Resident ID #1 stated being struck with a walking cane, wanted to press charges, and that Resident ID #2 admitted to striking Resident ID #1, leading to an arrest on one count of felony assault with a dangerous weapon. The facility’s failure to assess, monitor, and implement effective interventions for Resident ID #2’s known and escalating aggressive behaviors, including failure to update the care plan after prior incidents and failure to fully implement psychiatric recommendations, resulted in this resident-to-resident altercation and injury, and the report states that this failure placed Resident ID #1 and other residents at risk of serious physical and psychosocial harm.
Failure to Implement Psychiatric Recommendations and Update Behavior Care Plan Leading to Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health services and care planning for a resident with a documented history of psychiatric conditions and aggressive behaviors. The resident was admitted in December 2024 with diagnoses including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed intact cognition with a BIMS score of 13/15 and documented physical and verbal behaviors during the look-back period. Over time, multiple behavioral incidents were recorded, including threats to slit another resident’s throat during a smoking session, verbal disputes with name-calling and threats, and a statement to another resident that if touched again the resident would be killed. Further documentation showed escalating behaviors, including an incident where the resident attacked a roommate with a cane over television volume and required ER transfer for psychiatric evaluation, throwing poker chips and yelling when not winning at Bingo, causing the roommate to avoid the shared bathroom due to inappropriate comments and frustration over the light being turned on at night, and throwing a lunch plate across the nurses’ station at a nursing assistant over portion size. The care plan, initiated in January 2025 for verbal aggression and resident-to-resident altercations, did not contain added interventions to address the resident’s physically aggressive behaviors toward others after the incidents on 2/21/2026, 3/9/2026, and 4/10/2026. The DNS later could not provide evidence that the care plan had been updated with interventions to mitigate the risk of these physically aggressive behaviors or to guide staff in ensuring the safety of other residents. On 4/23/2026, a psychiatric evaluation recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order dated 4/24/2026 implemented trazodone 25 mg twice daily as needed for insomnia only, and the record lacked evidence that agitation and anxiety were included as indications for use as recommended by the consulting psychiatrist. Both the RNP and the DNS stated it was their expectation that the trazodone order would have included agitation and anxiety. Following this incomplete implementation of the psychiatric recommendation and the lack of updated behavioral interventions in the care plan, a resident-to-resident altercation occurred on 4/27/2026 in which the resident struck another resident with a cane, causing a laceration to the left eyebrow that required closure with steri-strips and ongoing wound treatment.
Failure to Properly Screen and Clear NA with Disqualifying Criminal History
Penalty
Summary
The facility failed to ensure that a prospective employee was properly screened and cleared for a history of abuse, neglect, exploitation, or misappropriation of resident property before hire. A nursing assistant, identified as Staff A, was hired on 11/18/2025 and was working independently as a NA. Prior to hire, a Bureau of Criminal Identification (BCI) check dated 11/6/2025 showed that Staff A had disqualifying information under federal and state law. Surveyor review after discovery of the positive BCI revealed that Staff A had an extensive criminal history. Despite this, the facility proceeded with the hire and allowed Staff A to complete orientation and work independently without obtaining or maintaining documentation specifying the nature of the disqualifying information, contrary to the facility’s Abuse, Neglect and Exploitation Policy, which requires screening and documentation of proof that such screening occurred. Subsequently, a facility-reported incident submitted on 4/17/2026 documented that a staff member reported witnessing Staff A grab a resident’s face and kiss the resident on the lips. A community-reported complaint submitted on 4/22/2026 alleged inappropriate interactions between the same NA and the same resident, and included a local police incident report indicating the resident’s family intended to pursue charges related to the incident. During interviews, the Human Resource Director stated that Staff A had disclosed disqualifying information related to a prior drug-related charge from about ten years earlier, but acknowledged there was no documentation specifying the nature of the disqualifying information and that this was known only by word of mouth. The Administrator stated she was aware that the BCI contained disqualifying information and that she exercised her own judgment in proceeding with the hire, and further acknowledged she did not receive documentation detailing the disqualifying information until it was brought to her attention by the surveyor.
Failure to Maintain Resident Clothing and Dignity
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity when the resident was unable to attend meals and activities with other residents because of a lack of appropriate clothing. The resident was admitted in May 2025 with diagnoses including anxiety disorder and post-traumatic stress disorder, and a care plan revised on 8/25/2025 described the resident as highly social and willing to participate in a variety of activities, with an intervention to provide reminders of scheduled events. During observation on 4/29/2026, the resident was found in the room wearing a hospital gown while other residents were in the dining room for lunch. Only one pair of pants and two T-shirts were observed in the room. The resident stated that the facility lost all of the resident's clothing, including shirts, pants, shorts, and socks, after they were sent to laundry services several months earlier and were never returned. The resident reported that the Administrator was told about the missing clothing, but no follow-up occurred and the clothing was neither located nor replaced. The record did not contain an admission inventory list of the resident's belongings, and the Administrator stated that laundry was handled by an outsourced company without a tracking system or documentation identifying which items belonged to which resident.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse when a nursing assistant (NA) was observed kissing the resident on the lips on more than one occasion. The resident, identified as having dementia and a Brief Interview for Mental Status (BIMS) score of 0/15 indicating severely impaired cognition, had been admitted in March 2026. On one occasion, a Certified Medication Technician (CMT) reported that while she was assisting the resident with breakfast, the NA entered the room, verbally expressed affection for the resident, made a kissing noise, leaned forward, and kissed the resident on the lips. This incident made the CMT uncomfortable, and she later discussed it with another NA. A separate staff member, another NA, reported that two days earlier she had observed the same NA enter the resident’s room while morning care was being provided, ask the resident if they remembered her, state that she loved the resident, then lean toward the resident, make a kissing sound, and kiss the resident on the mouth with full lip-to-lip contact. This second NA did not report the incident at the time because she was fearful of the NA involved and only came forward after learning of the later incident. The facility’s abuse, neglect, and exploitation policy defined sexual abuse as a non-consensual sexual act of any type with a resident and required protections for each resident’s health, welfare, and rights, as well as screening of potential employees for a history of abuse. Despite this policy, the resident with severely impaired cognition was subjected to repeated non-consensual kissing by the NA.
Failure to Investigate Allegations of Resident-to-Resident Sexual Inappropriateness
Penalty
Summary
The facility failed to ensure that allegations made by residents were recognized as possible abuse by staff and that all allegations were investigated for Resident ID #41, who was admitted with diagnoses including dementia and traumatic brain injury. A facility policy titled, Abuse, Neglect and Exploitation, stated that an immediate investigation is warranted when suspicion of abuse, neglect, exploitation, or reports of abuse, neglect, or exploitation occur. A progress note written by an RN documented that a resident reported Resident ID #41 was being inappropriate with another resident. Subsequent records included psychiatric evaluations stating the resident was being seen due to increased sexually inappropriate behaviors toward other residents and that sexual impulses may present an unsafe environment for other patients in the facility. Staff interviews revealed that Resident ID #41 had been observed touching other residents' shoulders and hands and required frequent redirection. The RN who documented the incident stated the behavior involved an attempted hug without contact and that both residents were separated and assessed, while the ADON and DON acknowledged they were unaware of the behavior or that the facility had not investigated the allegations. The Administrator also acknowledged that an investigation had not been completed to determine what sexually inappropriate behavior had occurred and that staff did not identify the allegation as possible abuse or investigate it immediately.
Failure to Follow Orders, Report Abuse, and Perform Ordered Wound Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for a resident with dementia and anxiety disorder who had a hearing deficit and complained of right ear wax buildup. The medical record showed an order for Debrox ear drops and a separate order to flush the right ear with warm water two times a day following Debrox usage for 5 days, but the record did not include a physician order for the Debrox solution. The April 2026 MAR showed the resident’s right ear was flushed six times, and the resident stated that the right ear still felt blocked. The RN acknowledged flushing the ear and was unaware whether Debrox had been given, while the DON stated the order had been entered incorrectly and that the ear should not have been flushed before Debrox administration. The NP stated the intended order was for Debrox twice daily for five days before irrigation and that she would not have ordered daily ear flushing. The facility also failed to report an allegation of abuse and failed to update the care plan for a resident with dementia after staff reported inappropriate interactions with a nursing assistant. A community complaint and police incident report indicated the family wanted to press charges, and the Administrator and DON confirmed that staff had reported witnessing the nursing assistant kiss the resident on two occasions. The record did not show that the allegation was reported to the provider, and the comprehensive care plan was not updated to reflect the allegation or any interventions related to the incident. The NP stated she was unaware of the incident and would have expected to be notified, and the ADNS acknowledged that the provider had not been notified and the care plan had not been updated. The facility further failed to follow a wound care order for a resident readmitted with peripheral vascular disease and cellulitis of the lower limb. The physician ordered cleansing open areas on the left lower leg with Vashe wound wash, applying xeroform to the wound bed, and wrapping with kling. During observation, the RN performing wound care did not use Vashe wash and instead cleansed the wound with normal saline. The RN acknowledged using normal saline rather than the ordered cleanser, and the DON stated she would expect the nurse to follow the wound orders as written.
Delayed Pain Medication for Resident with Migraine
Penalty
Summary
Safe, appropriate pain management was not provided for Resident ID #17, who was admitted with diagnoses including migraines and chronic pain. The resident’s care plan dated 4/20/2026 included a goal for the resident to verbalize adequate pain relief and an intervention to respond immediately to any complaint of pain. The physician ordered Butalbital-APAP-Caffeine 50-300-40 mg, 1 capsule every 12 hours as needed for migraine pain. On 4/29/2026 at 10:30 AM, the resident was observed in the hallway complaining of a migraine, moaning in pain, and holding his/her head. At 10:34 AM, an NA reported to an LPN that the resident wanted pain medication, and at 10:37 AM the resident continued to complain of migraine pain and told an RN about the pain, but the RN stated she did not have keys to the medication cart and could not get any pain medication. The resident continued to complain of severe head pain, returned to the room to lie down at 10:40 AM, and the LPN was still off the unit at 10:42 AM. The resident was not assessed when the LPN returned, and the medication was not administered until 11:10 AM, 40 minutes after the initial complaint. The resident later reported pain rated 7 out of 10, and the DON acknowledged that a resident should not wait 40 minutes for pain medication.
Missed Antibiotic Doses Not Reported to Provider
Penalty
Summary
The facility failed to ensure that Resident ID #17 was free from significant medication errors when the resident missed 6 doses of a prescribed antibiotic. The resident was admitted in April 2026 with diagnoses including surgical aftercare and complication of surgical and medical care, and had a physician order dated 4/3/2026 for Cefadroxil 500 mg by mouth twice daily for 14 days. Review of the April 2026 MAR showed missed doses on 4/3 at 8:00 PM, 4/6 at 8:00 PM, 4/11 at 8:00 PM, 4/12 at 8:00 AM, 4/14 at 8:00 PM, and 4/17 at 8:00 AM. The record did not show that the provider was notified of the missed antibiotic doses. During interview, the RN acknowledged the 6 missed doses and stated they should have been reported to the provider. The Medical Director stated she was unaware of the missed doses and said she would have extended the antibiotic course if she had known. The DON also acknowledged the missed doses and stated she would expect the provider to be informed if a resident misses any dose of an antibiotic.
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