Adviniacare Summit Commons, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Providence, Rhode Island.
- Location
- 99 Hillside Avenue, Providence, Rhode Island 02906
- CMS Provider Number
- 415129
- Inspections on file
- 50
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 15 (2 serious)
Citation history
Health deficiencies cited at Adviniacare Summit Commons, Llc during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, dementia, severe cognitive impairment, documented exit-seeking behavior, and a care plan identifying high elopement risk and the use of a wander guard was inadequately supervised. Earlier in the day, an LPN observed the resident attempting to open an exit door and redirected the resident, who was later last seen in their room. The resident subsequently exited a secured unit through a stairwell door that only briefly alarmed and was not connected to the wander guard system, descended to a basement level, and left through an exterior door. Because wander guard sensors were only placed at elevators and not at exit doors or stairwells, the resident’s departure went undetected until a Code Orange was called and the elopement protocol initiated, after which staff located the resident off premises and returned the resident to the facility.
A cognitively intact resident with spinal stenosis and post-stroke hemiplegia/hemiparesis was discharged from the hospital with documented referrals to a spine center for evaluation and possible spinal steroid injections, which were reiterated in a later provider note citing ongoing lower extremity weakness. Despite these physician-ordered referrals and the resident’s repeated attempts to reach the appointment scheduler, the facility did not schedule or facilitate the neurosurgical consultation. The unit secretary, who was responsible for scheduling, reported being unaware of the referrals, and neither she nor the DON could provide any evidence that efforts were made to arrange the appointment, leading to a prolonged delay in the resident’s surgical follow-up.
Two residents with severe cognitive impairment and known behavioral issues were not adequately protected from abuse, resulting in both physical and sexual incidents. In one case, a resident with severe dementia and intrusive wandering repeatedly entered others’ rooms without effective new interventions, culminating in an altercation where another cognitively intact resident forcefully pushed the wanderer, causing a fall, a left femoral neck fracture, and skin tears. In another case, a resident with Alzheimer’s disease, vascular dementia, severe cognitive impairment, and a documented history of sexually inappropriate behavior was found undressed from the waist down in bed attempting sexual intercourse with a severely cognitively impaired, non-consenting resident who also wandered. Staff intervention revealed perineal redness in the victim, and the aggressor became combative, brandishing scissors and threatening staff. The DON could not provide evidence of enhanced interventions to address the intrusive wandering or to ensure separation and protection from resident-to-resident sexual abuse.
Surveyors found that the facility did not maintain an effective emergency preparedness training program for multiple existing staff members. The facility’s own assessment stated that staffing would be adjusted based on staff education to protect resident health and safety, yet records showed no evidence that several long‑term and more recently hired staff had completed required emergency preparedness training. In an interview, the DON could not produce documentation of this training and acknowledged that it was her expectation that these staff would have received it.
A resident with dementia, severe cognitive impairment, hemiplegia after stroke, and a history of falls was observed seated in a wheelchair with an elevated-arm lateral support and a black Velcro strap securing the right arm, which limited movement while the resident attempted to self-feed. The NA reported the strap was present daily as part of the chair, while the DON and Director of Rehab were unaware of or uncertain about its intended use and removed it during the surveyor interaction. Record review showed no physician order, no restraint assessment, no documented medical symptom being treated, no evidence of least restrictive alternatives, and no indication of restraint use on the MDS, and the NP stated the arm strap would be considered a restraint and should not be in place.
A resident with dementia experienced multiple bruises and a skin tear to the arms over several documented occasions, with notes indicating the resident was unable to explain how the injuries occurred. Facility policy required incident reporting, supervisory follow-up, and a comprehensive internal investigation for such incidents, but clinical records contained no evidence that any investigation was initiated. In an interview, the DON confirmed she could not provide documentation that these injuries of unknown origin had been investigated.
A resident with dementia, post-stroke hemiplegia, severe cognitive impairment, and documented weight loss had physician orders and a care plan for 1:1 feeding assistance and Glucerna 237 cc PO three times daily. Surveyors observed the resident seated in a wheelchair with the right arm strapped to the chair, attempting unsuccessfully to self-feed while staff only set up the meal and did not provide 1:1 assistance until prompted. The assigned RN was unaware of the 1:1 feeding order. Later, the resident was observed unable to lift a cup containing the ordered Glucerna supplement, and the med tech assisted with intake only after the surveyor intervened. The DNS confirmed her expectation that staff should have provided 1:1 meal assistance and ensured supplement administration as ordered.
Surveyors found that the facility did not follow its own policy or professional standards for pressure ulcer prevention and care for two residents. One resident with dementia and a Stage 3 heel pressure ulcer had weekly skin checks signed as completed, but the required detailed wound assessments were missing on multiple weeks, and the resident received two conflicting topical treatments (Silvadene and A & D) simultaneously for over two weeks after the wound physician had changed the treatment plan. Another resident with dementia and post-stroke hemiplegia, identified as at risk for pressure ulcers, did not have weekly skin checks documented over several weeks, and later developed a new Stage 2 coccyx pressure injury that was not consistently or thoroughly assessed on subsequent weekly body audits, with one audit not reflecting any skin impairment.
The facility did not complete required annual performance evaluations for multiple NAs. Personnel file review showed no documented annual evaluations for four NAs hired over several years, and the DON was unable to provide evidence that these evaluations had been conducted within the past 12 months, resulting in a deficiency related to required NA performance reviews.
The facility failed to revise care plans to reflect current needs for g-tube management and recurrent falls. A resident with a g-tube and tactile impulses had physician orders for continuous use of an abdominal binder, but the care plan, last updated months earlier, did not include this intervention, as confirmed by the DNS. In addition, one resident with a history of frequent falls and another resident with dementia and unsteadiness experienced multiple falls, yet one care plan was not updated after numerous fall events and the other lacked any fall-related focus area, with the DNS unable to provide evidence of appropriate care plan revisions.
A resident with a G-tube and severe cognitive impairment, dependent on staff for dressing, had physician orders to wear an abdominal binder at all times, except during ADL care or showering, to help manage the gastrostomy site. A complaint alleged the resident frequently damaged or pulled out the G-tube and that proper precautions, including consistent binder use, were not implemented. During surveyor observation, the resident was found in bed without the abdominal binder, which was located on a shelf across the room. An LPN acknowledged she had not assisted the resident to put the binder on that morning, and the DON stated she would have expected the binder to be in place, demonstrating failure to follow the physician’s orders.
The facility did not provide a qualified dietitian to assess and address the nutritional needs of four residents with complex medical conditions, despite multiple provider recommendations and orders for dietary consults. Staff interviews confirmed that no dietitian had been available for several months, resulting in residents not receiving required dietary evaluations.
A resident with progressive MS was not weighed monthly as required by facility policy, resulting in a significant weight gain of 24.3 lbs going undetected for over three months. Staff interviews confirmed that ongoing weight monitoring was not performed or ordered, and the lapse was only discovered after surveyor inquiry.
A resident with intact cognition and complex medical needs repeatedly refused prescribed medications, but staff attempted to administer them by mixing them into a nutritional supplement without a provider's order and physically restraining the resident. These actions, including unauthorized medication administration and failure to document and report refusals, violated the resident's rights and facility policy.
The facility did not follow its water management program, failing to conduct required water testing, fixture flushing, and HVAC maintenance, as well as not documenting these activities. Multiple water samples tested positive for Legionella, and a resident with dementia and adjustment disorder was hospitalized with Legionella pneumonia after developing fever and sepsis. Staff confirmed that the water management plan was not followed, and required mitigation steps were not performed or documented.
A resident with severe cognitive impairment and a history of stroke was found with a bed sheet tied across the abdomen and secured to the mattress, restricting movement. Staff routinely removed and reapplied the sheet during care, but there was no physician's order, assessment, or documentation of medical symptoms to justify restraint use. The DON acknowledged the restraint, and facility policy defined such use as a physical restraint.
The facility did not maintain required indoor temperatures, with areas reaching up to 88°F, and failed to act on resident complaints about broken air conditioning. A resident was observed in distress due to the heat, and the maintenance log confirmed prior reports of malfunctioning AC. The facility was unaware of the excessive temperatures until informed by surveyors, and the acting Maintenance Director admitted the AC units were inadequate for the space.
A resident with end stage renal disease and dysphagia, who experienced significant weight loss, did not have a person-centered, comprehensive care plan addressing their nutritional needs. Although assessments indicated the need for a therapeutic, mechanically altered diet, the care plan lacked individualized interventions and specific approaches. Staff interviews confirmed the absence of a focused nutrition section and noted the facility had not had an RD for several months.
A resident with end stage renal disease and dysphagia experienced significant unaddressed weight loss and signs of severe malnutrition. Despite policy requiring notification and intervention for significant weight changes, staff did not reweigh the resident or notify the provider. The dialysis center repeatedly raised concerns about the resident's declining nutritional status, but communication from the facility was lacking, and the facility had no on-site RD at the time.
A resident with severe pain and complex medical needs did not receive appropriate pain management after an order for hydromorphone every 4 hours PRN was discontinued in error, leaving only a once-daily PRN order. Nursing staff did not contact the on-call provider when the resident requested additional pain medication, resulting in the resident calling 911 and being transferred to the hospital for pain control.
A resident with end stage renal disease and failure to thrive experienced significant weight loss and a fall, but the facility did not communicate these changes to the dialysis center as required by policy. The dialysis center staff reported ongoing concerns about the resident's malnutrition and lack of communication, and facility records confirmed that critical information was not shared.
A resident who required two-person assistance for transfers sustained fractured ribs after a nursing assistant attempted to pull the resident backwards in a shower chair up a steep incline into a shower stall. The chair tipped and broke, causing the resident to fall and require hospital admission. The incident occurred despite manufacturer warnings against using the chair on an incline and the resident's care plan specifying the need for two staff during transfers.
The facility failed to label and date food items in the main kitchen and kitchenettes, as observed by surveyors. Various food items, including sandwiches, sausage links, cakes, and salads, were found without labels or dates. Staff members acknowledged the oversight, confirming that the items should have been labeled, dated, or discarded according to regulations and facility policy.
The facility failed to manage fluid intake and communicate critical information for residents requiring dialysis. Two residents with fluid restrictions had no documentation of their fluid intake, and the facility lacked a system for tracking this. Additionally, the facility did not notify the dialysis center of medication refusals and falls for two residents, despite policy requirements. Staff interviews confirmed these deficiencies, highlighting a systemic issue in policy adherence.
The facility did not complete annual performance reviews for six nurse aides, as required. Personnel records for these staff members lacked evidence of evaluations within the past year. The Director of Nursing Services could not provide documentation of completed evaluations, confirming the deficiency.
The facility's QAPI/QAA committee failed to include required members, as the Infection Preventionist was absent from a meeting, and both the Infection Preventionist and DNS were absent from two subsequent meetings. The Administrator could not provide evidence of their attendance.
The facility failed to protect residents' personal and medical records, as a Survey History Binder in the main lobby contained identifying information of 21 residents from previous surveys. The Administrator could not provide evidence of protecting this information, resulting in a deficiency.
A resident with a gastrostomy tube was not receiving the prescribed Jevity 1.2 cal at the correct rate, nor the correct water flush rate. The feeding was set at 60 mL/hr instead of 75 mL/hr, and the water flush was set at 350 mL per shift instead of 235 mL. The water flush bag was empty, and the feeding pump was not properly closed, causing an alarm. Staff interviews confirmed these discrepancies.
A resident with dementia and dysphagia experienced significant weight loss, but the facility failed to notify the physician or NP as required by policy. The DON expected the dietician to inform the physician, but the NP was unaware of the weight loss.
The facility failed to accurately document and implement enhanced barrier precautions (EBP) for two residents. One resident's EBP order was not discontinued after wound resolution, and another resident with a history of MRSA had no EBP signage or PPE outside their room despite existing orders. The DNS expected proper signage and PPE verification before order sign-off.
A facility failed to implement enhanced barrier precautions (EBP) for a resident with a history of MRSA, as required by their policy. Despite a physician's order for EBP, surveyors observed no signage or PPE outside the resident's room. Staff interviews confirmed the oversight, acknowledging the lack of compliance with the EBP order.
A resident was administered an incorrect total dose of Levothyroxine due to a failure to update the MAR following a change in the prescribed dosage. Despite a new order to decrease the dosage, both the original and new doses were given together, resulting in a significant medication error. The error was not identified by the facility until pointed out by a surveyor.
A resident with essential hypertension did not receive prescribed Nimodipine due to pharmacy delivery delays and refusals. The facility failed to notify the provider about missed doses and refusals, leading to a significant medication error.
A resident with diabetes was administered 8 units of Insulin Lispro by an LPN without an active physician's order, instead of the prescribed Novolog. The LPN mistakenly believed the two insulins were the same. The error was confirmed by the DNS and the resident's physician, highlighting a significant medication error with potential risk for the resident.
The facility did not document all required components of its facility-wide assessment, specifically lacking a plan for recruitment and retention of direct care staff. This was identified during a review of the 'Facility Assessment' document and confirmed by the Administrator.
A facility failed to maintain complete medical records for a resident with diabetes who required insulin. The resident's blood sugar levels exceeded the threshold for contacting the provider on two occasions, but there was no documentation of such contact. Interviews with LPNs confirmed the lack of documentation, and the DON could not provide evidence of complete records, indicating a deficiency in record-keeping practices.
A resident with diabetes had a physician's order for insulin administration using a pen injector. However, an LPN used an insulin syringe instead of the pen needle applicator due to the unavailability of the applicators on the unit. This deviation from the prescribed method was acknowledged by the staff and the Director of Nursing Services.
A cognitively impaired resident eloped from a facility, remaining unaccounted for over six hours before being found by police 13.2 miles away. Despite having a wander guard system, the facility failed to notice the resident's absence promptly and did not implement safety measures upon their return. The administration incorrectly classified the incident as a Leave of Absence, failing to follow their elopement policy, which placed the resident at risk.
A resident with burns and an allograft procedure was not provided with appropriate wound care as per professional standards. The facility failed to document the resident's burn and allograft in initial assessments and did not act on a burn clinic's recommendation for daily treatment for eight days. Additionally, blisters on the resident's right foot were not covered or documented in subsequent audits. The LPN and wound nurse were unaware of these issues, and the DON acknowledged the oversight.
A resident with a pressure ulcer did not receive necessary treatment for 18 days due to a lack of communication and follow-up on physician's orders. The facility's contracted wound physician recommended a treatment, but it was not implemented, leaving the wound open and causing pain. Staff were unaware of the pressure injury and the recommended treatment, leading to a deficiency in care.
A resident with multiple health conditions was mistakenly given Suboxone, a medication not prescribed for them, due to an LPN's failure to properly identify the resident before administration. The error was confirmed by the Unit Manager and the DON, revealing a lapse in the facility's medication administration procedures.
Deficiencies were noted in food storage and serving practices, with cold food items being served above acceptable temperatures, such as tuna salad sandwiches at 51.2°F and ham on a Chef Salad plate at 55.2°F. Additionally, some refrigerated items lacked proper labeling and were stored past their use by dates, including Dannon Light +Fit yogurt with a use by date of 3/11/2024. Staff compliance with food safety regulations was also observed to be lacking, with improper use of hair restraints and beard coverings in the main kitchen.
The facility failed to maintain an infection prevention and control program for residents using CPAP and BIPAP devices. The facility did not adhere to its own policy for cleaning and disinfecting these devices, as confirmed by interviews with the Infection Preventionist and the Director of Nursing Services.
The facility failed to obtain laboratory services for a resident prescribed Depakote. Despite a new order to check the valproic acid level in 2 weeks, the lab was not drawn as required. Interviews with the LPN, Physician, and DON confirmed the oversight.
A resident with diabetes experienced an unresponsive episode due to critically low blood sugar levels. A nurse administered only sterile water instead of reconstituted Glucagon, as she was unaware of the need to reconstitute the medication. This error was discovered by another nurse who administered the correct dose. Investigation revealed that several nursing staff lacked training and competency assessments for Glucagon administration, contributing to the deficiency.
A resident experienced a critical hypoglycemic episode due to improper insulin administration and a medication error involving Glucagon. The resident received insulin despite orders to hold it for blood sugar levels below 200 mg/dl, leading to a severe drop in blood sugar. During the emergency response, the initial Glucagon dose was not reconstituted correctly, delaying treatment. Staff interviews revealed a lack of awareness and training regarding medication administration parameters.
Failure of Elopement Prevention and Supervision for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and maintain an effective elopement prevention system for a resident assessed as a high elopement risk. The resident had Alzheimer’s disease, dementia, severe cognitive impairment (BIMS score of 00), a documented history of exit-seeking behaviors, and a care plan identifying high elopement risk, prior elopements, recent attempts to leave, verbalizations about leaving, and wandering behavior requiring a wander guard. On the morning of the incident, an LPN observed the resident attempting to open the unit exit door at approximately 9:30 AM; the resident was redirected and escorted back to the dining room. The resident was last seen in their room at approximately 10:00 AM. Despite residing on a secured unit and wearing a wander guard, the resident eloped from the unit via a stairwell door that alarmed when opened but stopped alarming after the door closed and after a period of time. The wander guard system was configured so that sensors were only located at the elevators and did not detect the resident at the unit exit doors or stairwell. The resident used the stairwell to descend several flights to the basement level and exited through a basement exterior door, leaving the building undetected. A Code Orange was not called and the elopement protocol not initiated until approximately 11:20 AM, at which time the resident had already traveled off premises and was later observed walking along a main road and crossing a four-lane street before being located and returned to the facility at approximately 11:45 AM.
Failure to Arrange Neurosurgical Follow-Up for Resident With Spinal Stenosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services were provided in accordance with professional standards of quality for a resident admitted with spinal stenosis and post-stroke hemiplegia/hemiparesis. The resident was admitted in October 2025 with diagnoses including spinal stenosis and left-sided weakness following a stroke. A Continuity of Care - Post-Acute Facility document dated 10/24/2025 indicated that, upon hospital discharge, a referral to a spine center was placed to evaluate the need for spinal steroid injections. A subsequent provider progress note dated 11/17/2025 documented the resident’s ongoing chronic lower extremity weakness related to lumbar disc protrusions and reiterated the need for outpatient neurosurgical follow-up, with an additional referral placed at that time. Record review and interviews showed that, despite these clear and repeated physician-ordered referrals, the facility did not schedule or facilitate the required neurosurgical consultation. The resident, who had a Brief Interview for Mental Status score of 14/15 indicating cognitive intactness and ability to express needs, reported making multiple unsuccessful attempts to contact the facility’s appointment scheduler to obtain the neurosurgical consultation for spinal injections. During an interview, the Unit Secretary responsible for scheduling appointments stated she was unaware of the referrals, and neither she nor the Director of Nursing Services could provide evidence that any efforts were made to arrange the neurosurgical appointment. A community complaint alleged that the resident waited approximately five months without resolution of the needed surgical follow-up appointment.
Failure to Prevent Resident-to-Resident Physical and Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse by not implementing effective, enhanced interventions for a resident with known intrusive wandering behaviors. One resident with severe dementia, a BIMS score of 0/15, and documented wandering that significantly intruded on the privacy and activities of others repeatedly entered other residents’ rooms on multiple dates, including 12/26/2025, 12/27/2025, 1/10/2026, and 1/12/2026. Progress notes documented that this resident wandered throughout the unit, entered other residents’ rooms, and required frequent or continuous redirection, with redirection having little effect. Despite these repeated incidents and evidence of escalation and ineffective redirection, there was no documentation that the facility implemented new or enhanced interventions to mitigate the risk of resident-to-resident altercations. On 1/13/2026, the same wandering resident entered the room of another resident with dementia but intact cognition, as evidenced by a BIMS score of 14/15. The cognitively intact resident reported that the wandering resident entered the room and refused to leave despite being told to do so. During the resulting altercation, the cognitively intact resident grabbed the wandering resident by both wrists and forcefully shoved the resident, causing the wandering resident to strike the wall and fall to the floor. Documentation and interviews indicated that the cognitively intact resident sustained skin tears to the backs of both hands, while the wandering resident developed visible hand/finger marks on the wrists and was unable to walk after the fall, complaining of pain. Hospital records showed that the wandering resident sustained a left femoral neck fracture requiring a left hip hemiarthroplasty, and physical therapy later recommended use of a Hoyer lift for transfers. The facility’s Abuse Prohibition Policy states that each resident has the right to be free from abuse, including the willful infliction of injury resulting in physical harm, pain, or mental anguish, and defines adverse events and abuse. The Director of Nursing Services acknowledged that the wandering behavior was related to the resident’s cognition and that the facility was aware of the resident’s ongoing intrusive wandering. She was unable to provide evidence that new interventions were implemented after the documented incidents on 1/10/2026 and 1/12/2026 when the resident entered other residents’ rooms and caused distress. The failure to implement appropriate interventions following these witnessed incidents placed the wandering resident at risk for resident-to-resident physical abuse and resulted in the physical altercation, the fall, the left femur fracture, and skin tears to the other resident’s hands. The deficiency also includes the facility’s failure to protect a resident from sexual abuse by another resident with a known history of sexually inappropriate behavior. One resident with Alzheimer’s disease, vascular dementia, a BIMS score of 5/15 indicating severe cognitive impairment, and the ability to ambulate with supervision or touch assistance had a care plan dated 11/29/2025 documenting sexually inappropriate behaviors toward other residents, including hugging and kissing. Nursing notes recorded that this resident had previously touched another resident on the chest/breast area and tried to kiss the resident, and that the resident had yelled and moved aggressively toward a nursing assistant who intervened. Despite this history, the resident was later found undressed from the waist down in bed with another severely cognitively impaired resident, attempting to engage in sexual intercourse. The other resident involved in the sexual incident had senile degeneration of the brain, a BIMS score of 0/15 indicating severe cognitive impairment, and a history of wandering daily with ambulation requiring supervision or touch assistance. This resident’s care plan identified a behavioral problem of wandering the unit, with interventions including providing for the immediate safety of the resident or other residents. On the night of the incident, staff found this resident lying in bed with the sexually inappropriate resident, with pants and brief lowered, while the other resident was on top attempting to engage in sexual intercourse. A skin assessment documented redness in the perineal area. The Director of Nursing Services reported that when staff attempted to separate the residents, the sexually inappropriate resident became very aggressive and combative, waving a pair of scissors and threatening staff while swinging the scissors. The responsible party for the cognitively impaired resident who was the target of the sexual behavior reported being informed of a prior interaction between the two residents in November 2025 and stated that facility staff had assured them the residents would be kept separated. The responsible party also stated that the resident did not understand and could not consent to a sexual relationship due to cognitive impairment and would not want the resident to engage in a sexual relationship with another resident. During interview, the Director of Nursing Services was unable to provide evidence that the cognitively impaired resident was kept free from resident-to-resident sexual abuse. The facility’s Abuse Prohibition Policy defines sexual abuse as non-consensual sexual contact of any type with a resident, including sexual harassment, sexual coercion, or sexual assault, and states the facility’s responsibility to ensure each resident’s right to be free from abuse.
Failure to Provide Required Emergency Preparedness Training for Existing Staff
Penalty
Summary
The facility failed to develop, implement, and maintain an effective emergency preparedness training program for existing staff, as required by its facility assessment. The facility assessment, last revised on 2/5/2026, stated that staffing would be adjusted based on staff education to ensure residents’ health and safety were maintained. Record review showed no evidence that four staff members—Staff H (hired 3/19/2015), Staff I (hired 10/11/2022), Staff J (hired 5/4/2021), and Staff K (hired 11/7/2024)—had completed emergency preparedness training. During an interview on 2/11/2026 at approximately 2:00 PM, the Director of Nursing Services (Staff M) was unable to provide documentation of emergency preparedness training for these staff and stated it was her expectation that such training would have been completed for them. This deficiency was identified as having the potential to impact all 163 residents in the facility, as well as an indeterminable number of staff and visitors, due to the lack of documented emergency preparedness education for these staff members.
Unauthorized Use of Arm Strap Restraint Without Assessment or Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from an unauthorized physical restraint. A resident with dementia, severe cognitive impairment (BIMS score 3/15), hemiplegia/hemiparesis following a stroke, and a history of repeat falls was readmitted with care plans addressing fall risk and the need for assistance with transfers and proper use of devices. The facility’s restraint policy defines physical restraints as any device attached to the body that the resident cannot easily remove and requires a specific physician order, including type, frequency, duration, and monitoring. Record review showed no documentation of a physician’s order, restraint assessment, identified medical symptoms being treated, or alternative interventions attempted for this resident, and the MDS assessment did not indicate any restraint use. During surveyor observations, the resident was seen in a wheelchair with an elevated-arm lateral body support, and the right arm was secured to the device with a black Velcro strap that restricted arm movement while the resident attempted to feed themself; the strap remained in place throughout the meal. The primary NA reported that the black strap was present every day and considered it part of the chair. The DNS stated she was unaware that an arm strap was in use, and the Director of Rehabilitation acknowledged the strap was in place but was unsure if it should be and stated he had never seen one like it with that device. When asked, the resident did not remove the strap before the DNS removed it. The NP confirmed that the resident should not have a strap on the right arm because it would be considered a restraint. The DNS was unable to provide evidence that the facility had assessed the need for a physical restraint, evaluated least restrictive alternatives, determined duration of use, or conducted required re-evaluations, as required by regulation and facility policy.
Failure to Investigate Repeated Injuries of Unknown Origin
Penalty
Summary
The facility failed to investigate injuries of unknown origin for a resident with dementia who was readmitted in July 2025. The facility’s abuse prohibition policy requires that incidents be identified and followed by an incident report, supervisory follow-up, and a comprehensive internal investigation with timely notification to appropriate agencies as warranted. Clinical record review showed multiple documented injuries for this resident, including a bruise to the right forearm and elbow on 11/6/2025, left forearm discoloration and a skin tear on 11/17/2025 when the resident was unable to verbalize how the skin tear occurred, a bruise on the right arm and redness on the right elbow on 12/2/2025 when the resident could not recall or report how the injury occurred, and a bruise on the left upper arm noted by a nursing assistant on 12/27/2025. Further record review did not show any evidence that an investigation was conducted to determine the origin of these bruises and skin tears. During an interview on 1/29/2026, the Director of Nursing Services confirmed she was unable to provide evidence that an investigation had been initiated for these injuries of unknown origin.
Failure to Provide Ordered 1:1 Feeding Assistance and Nutritional Supplement
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders, professional standards, and the resident’s care plan for a resident requiring one-to-one assistance with meals and supplements. The resident, who was readmitted with dementia, hemiplegia/hemiparesis following a stroke, and a history of repeat falls, had a BIMS score of 3/15 indicating severe cognitive impairment and required supervision or touching assistance with meals. A nutritional assessment documented gradual weight loss over six months with varied intake and recommended continuation of Glucerna 237 cc PO three times daily. The care plan, last revised in mid-January, specified one-to-one feeding assistance with all meals. Physician orders included Glucerna 237 cc PO three times daily, one-to-one assist with meals, and one-to-one feeding. Despite these orders and care plan interventions, surveyor observations showed the resident seated in a wheelchair with a lunch tray placed in front and attempting to self-feed while the right arm was strapped to the wheelchair support, limiting effective use. During this continuous observation, the resident’s tablemate repeatedly stated that the resident could not feed themself and expressed a desire to help, while a nursing assistant stated that the resident was going to feed themself and acknowledged later that one-to-one assistance was not being provided until the surveyor pointed it out. The charge RN assigned to the resident reported being unaware of the one-to-one meal assistance requirement, though he acknowledged the existence of the physician order. In a subsequent observation, the resident was left with a cup containing a brown liquid identified as the ordered Glucerna supplement and was unable to lift the cup to drink; the medication technician confirmed it was the supplement and only assisted the resident after the surveyor brought it to her attention. The DNS stated that her expectation was that staff would provide one-to-one assistance with meals and ensure the supplement was administered without needing surveyor prompting.
Failure to Provide Consistent Assessment and Appropriate Treatment for Pressure Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new pressure ulcers for two residents with actual or potential pressure injuries. Facility policy required that residents with pressure injuries or at risk for skin breakdown receive weekly body audits by licensed staff, with pressure injuries assessed and documented at least weekly, including location, measurements, stage, drainage, odor, and detailed description of the wound bed, edges, and peri-wound area. For one resident admitted with dementia and muscle weakness and an existing Stage 3 pressure ulcer, the record showed physician orders for weekly skin assessments on a specific shift, and treatment administration records documented that skin checks were completed on several dates. However, the corresponding weekly body audits did not include the required detailed assessment elements for the Stage 3 pressure injury on multiple dates. Further review of this resident’s wound care showed that the contracted wound physician initially recommended daily treatment of a left lateral heel Stage 3 pressure ulcer with normal saline cleansing, Silvadene (SSD), and a silicone dressing, and a physician’s order was entered to that effect. A subsequent wound physician progress note revised the recommendation to daily cleansing with normal saline, application of A & D ointment, and leaving the wound open to air, and a new physician’s order was entered reflecting this change. The clinical record did not show that the original Silvadene order was discontinued, and treatment administration records indicated that both Silvadene and A & D ointment were administered to the same heel wound for a period of 16 days, contrary to the wound physician’s revised recommendation. During interview, the nurse practitioner stated that her expectation was that the Silvadene would have been discontinued when the A & D treatment was ordered. For a second resident readmitted with dementia, hemiplegia and hemiparesis following a stroke, a quarterly MDS assessment identified the resident as at risk for developing pressure ulcers. Weekly body audits documented a skin check with no skin impairment on one date in December, but there was no evidence of any weekly skin check from that date through early January. A Pressure Injury Evaluation form completed in mid-January identified a newly developed Stage 2 pressure area on the coccyx. Subsequent weekly body audits completed later in January did not document the required detailed assessment of this Stage 2 pressure injury, including location, measurements, drainage, odor, or description of the wound bed, edges, and peri-wound area, and one audit failed to identify any skin impairment at all. In interview, the DON stated that her expectation was that weekly skin checks be completed and that any pressure area be fully assessed and documented with the required elements.
Failure to Complete Annual Performance Evaluations for Nursing Assistants
Penalty
Summary
The facility failed to complete annual performance evaluations for all reviewed nursing assistants (NAs) at least once every 12 months. Review of personnel records for four NAs showed no evidence of an annual performance evaluation for Staff H, hired on 3/19/2015; Staff I, hired on 10/11/2022; Staff J, hired on 5/4/2021; and Staff K, hired on 11/7/2024. During an interview on 2/11/2025 at approximately 2:00 PM, the Director of Nursing Services (Staff M) was unable to provide documentation that performance evaluations had been completed for these NAs within the previous 12 months. This lack of documented annual performance reviews for all four NAs reviewed constituted the identified deficiency.
Failure to Revise Care Plans for G-Tube Management and Recurrent Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents’ care plans were revised by the interdisciplinary team to reflect current physician orders and changes in condition, specifically related to a gastrostomy tube (g-tube) and recurrent falls. One resident with a history of a cerebrovascular accident, muscle weakness, and a g-tube had physician orders dated 9/4/2025 to encourage use of an abdominal binder at all times on every shift, and a subsequent order dated 1/7/2026 specifying that the resident was to wear the abdominal binder, with removal allowed only during ADL care or showering. The resident’s care plan, which included a focus area initiated on 6/24/2025 for behavior problems of tactile impulses (including pulling the g-tube), was last revised on 8/26/2025 and did not include the abdominal binder as an intervention. During an interview, the DNS acknowledged that the care plan was not revised to include the abdominal binder. The deficiency also includes failure to revise care plans in response to multiple falls for two residents. One resident experienced multiple falls on several dates in December 2025 and January 2026. Although this resident had a care plan focus area initiated on 2/3/2025 for frequent falls secondary to generalized weakness, decreased neuromuscular coordination, and cognitive impairment, the last revision was on 12/2/2025 and did not include added interventions related to the subsequent falls. The DNS was unable to provide evidence that the care plan was updated following these events. Another resident, admitted with dementia and unsteadiness on feet, sustained multiple falls in December 2025. Review of this resident’s care plan failed to show any focus area for falls, and the DNS could not provide evidence that the care plan was revised to address falls.
Failure to Follow Physician Orders for Abdominal Binder Use with G-Tube Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with a gastrostomy tube received care in accordance with professional standards and physician orders regarding the use of an abdominal binder. The resident, admitted with a diagnosis including a gastrostomy tube and assessed as having severe cognitive impairment with dependence on staff for dressing, had physician orders dated 9/4/2025 to encourage use of an abdominal binder at all times on every shift, and a subsequent order dated 1/7/2026 specifying that the resident was to wear the abdominal binder and may remove it only during activities of daily living care or showering. A community complaint alleged that the resident frequently damaged or pulled out the G-tube and that the facility did not implement proper precautions, including use of an abdominal binder, to prevent the resident from pulling out the tube. During surveyor observation, the resident was seen in bed without the abdominal binder in place under the shirt, and the binder was found on a shelf across the room from the resident’s bed. In the presence of the surveyor, an LPN acknowledged that the resident was not wearing the abdominal binder and admitted she had failed to assist the resident to put it on that morning. In a subsequent interview, the Director of Nursing Services stated that she would have expected the abdominal binder to be in place on the resident. These observations and interviews demonstrated that staff did not follow the physician’s orders for continuous use of the abdominal binder, except during specified care activities, resulting in the cited deficiency.
Failure to Provide Qualified Dietitian Services for Residents
Penalty
Summary
The facility failed to provide a qualified dietitian to assess and address the individual nutritional needs of four residents, despite multiple documented recommendations and physician orders for dietary consultations. Clinical record reviews revealed that residents with complex medical conditions, including progressive multiple sclerosis, myxedema coma, dysphasia, type two diabetes, and Alzheimer's disease, did not receive dietary consults during their admissions. In several cases, care plans and progress notes specifically identified the need for dietary evaluation, and providers placed orders or made recommendations for dietitian involvement, but there was no evidence that these consults were completed. Interviews with staff, including the Director of Nursing Services (DNS) and a Nurse Practitioner, confirmed that the facility had not had a dietitian on staff for several months and that residents were not being seen by a dietitian as required. The DNS acknowledged the expectation for residents to be seen by a dietitian on admission, quarterly, and as indicated, but was unable to recall when the last clinical assessment by a dietitian occurred. The lack of dietary consultations persisted despite repeated requests and recommendations from both residents and healthcare providers.
Failure to Monitor Resident Weight as Required by Policy
Penalty
Summary
The facility failed to ensure ongoing monitoring of a resident's weight status, as required by its own policy and standard clinical practice. The policy specified that residents should be weighed weekly for the first four weeks after admission and then monthly unless otherwise indicated, with all weights documented in the medical record. A resident with progressive Multiple Sclerosis was admitted and initially weighed according to policy, but after the last recorded weight, no further weights were obtained for over three months. There was also no evidence of a current physician's order to continue monthly weight monitoring, and this lapse was not identified by facility staff. Interviews with the Nurse Practitioner and the Director of Nursing Services confirmed that they were unaware of the missed weight checks and acknowledged the failure to monitor the resident's weight as required. When a weight was finally obtained after the surveyor's inquiry, it was found that the resident had gained 24.3 pounds since the last recorded weight. This significant weight gain went undetected due to the lack of ongoing monitoring, contrary to facility policy and expectations.
Failure to Honor Resident's Right to Refuse Medications
Penalty
Summary
A deficiency occurred when facility staff failed to honor a resident's right to refuse medications and treatments. The resident, who had diagnoses including myxedema coma and dysphagia and demonstrated intact cognition, repeatedly refused prescribed medications. Despite these refusals, staff made multiple attempts to administer the medications, including mixing them into a nutritional supplement without a provider's order. On one occasion, a medication technician enlisted another staff member to physically hold the resident's arm while attempting to administer the medications, resulting in the resident spitting out the mixture and expressing distress. Progress notes and staff interviews confirmed that the resident was agitated, cried, and verbally objected to the administration attempts. Facility policy states that residents have the right to refuse medications and treatments, and staff are expected to document and report refusals rather than attempt to coerce or force compliance. Interviews with the DON and Nurse Practitioner confirmed that medications should not be mixed into food or drink to coerce residents, and refusals should be documented and reported to medical providers. The actions taken by staff, including physical restraint and unauthorized mixing of medications, directly violated the resident's rights and facility policy.
Failure to Implement Water Management Program Leads to Legionella Infection
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not implementing and following a water management program (WMP) in accordance with industry standards and CDC guidelines. The facility's own policies required annual water program assessments with a qualified contractor, regular flushing and disinfection of water fixtures, quarterly water testing for Legionella, and documentation of HVAC preventative maintenance. However, records showed that the facility did not conduct annual assessments from 2019 through 2024, did not perform or document quarterly water testing in several required months, and failed to maintain records of regular flushing, disinfection, and HVAC maintenance as outlined in their policies. Water sample results from August 2024 revealed multiple positive findings for Legionella in various locations throughout the facility, with concentrations indicating poor control of Legionella growth. Despite these findings and recommendations from a contracted water safety company for ongoing quarterly sampling and weekly flushing of infrequently used fixtures, the facility did not provide evidence of continued mitigation steps after March 2025. Staff interviews confirmed that the water management plan was not followed, and required flushing and disinfection had not been performed as scheduled. A resident admitted in August 2025 with dementia and adjustment disorder developed a fever and was hospitalized with sepsis and pneumonia. Hospital records confirmed a positive urine test for Legionella, and the resident required an extended course of antibiotics. The failure to implement and document the required water management and infection control measures resulted in a resident contracting Legionella pneumonia, with the facility unable to demonstrate compliance with its own policies or regulatory expectations.
Resident Restrained with Tied Bed Sheet Without Assessment or Order
Penalty
Summary
A resident with a history of cerebral infarction, anxiety, and severe cognitive impairment was found to have a bed sheet tied across their abdomen and secured to the mattress, restricting movement. The resident was admitted with a high risk for falls and required assistance for transfers and personal hygiene, but was able to reposition independently in bed. Multiple unwitnessed falls from bed were documented in the weeks prior to the incident. Staff interviews revealed that several nursing assistants and a speech language pathologist observed the sheet tied across the resident's waist, and staff routinely removed and reapplied the sheet during care without knowledge of its intended purpose. Record review showed there was no physician's order, assessment, or documentation of medical symptoms justifying the use of a restraint, nor evidence of alternative interventions attempted prior to restraint use. The facility's policy defined such use of sheets as a physical restraint, and the Director of Nursing Services acknowledged the resident was physically restrained. The facility was unable to identify the staff member responsible for initiating the restraint, and written statements confirmed the practice of removing and reapplying the sheet during care.
Failure to Maintain Safe Indoor Temperatures During Hot Weather
Penalty
Summary
The facility failed to maintain a safe and comfortable temperature range for residents, as required by policy, with temperatures on the 5th floor reaching 88°F and the 3rd floor reaching 85°F. Surveyor observations confirmed that the environment was uncomfortably warm, and the facility was unaware of the excessive temperatures until notified by the surveyor. The facility's own policy states that when temperatures reach 82°F or higher, staff should be assigned duties to reduce exposure to excessive heat, and room changes should be made for fragile residents, but these actions were not documented as being taken. A resident was observed exiting their room, appearing to be in distress with heavy breathing, a red face, perspiration, and a wet shirt, and reported to staff that their air conditioner was broken. This resident had previously reported the issue to staff, as documented in the maintenance log, but the problem persisted. The acting Maintenance Director acknowledged that the air conditioning units were insufficient for the area and that the recorded temperatures exceeded the facility's policy threshold. These conditions were corroborated by community complaints and weather records indicating high outdoor temperatures.
Failure to Develop Person-Centered Nutrition Care Plan for Resident with Weight Loss
Penalty
Summary
A deficiency was identified when the facility failed to develop a person-centered, comprehensive care plan addressing the nutritional needs of a resident who experienced significant weight loss. The resident, admitted with diagnoses including end stage renal disease and dysphagia, had a physician's order for a mechanical soft, ground texture diet with nectar thick liquids. Documentation showed that a Care Area Assessment (CAA) was completed, indicating the need for a therapeutic and mechanically altered diet, and that this concern was triggered for care planning. However, review of the resident's care plan revealed no focused CAA for nutrition, nor any individualized, person-centered interventions or approaches to address the resident's specific needs and required level of assistance. Interviews with facility staff confirmed the deficiency. The Speech Pathologist reported that the resident was receiving speech therapy for dysphagia and was scheduled for a Modified Barium Swallow test due to frequent refusal of the prescribed diet. The DON acknowledged the absence of a Registered Dietitian since March and reliance on a Corporate Dietician as needed. Both the Assistant DON and the Administrator confirmed that the care plan lacked a focused nutrition section with specific, individualized interventions for the resident.
Failure to Address Significant Weight Loss and Malnutrition
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident with end stage renal disease and dysphagia, resulting in significant weight loss. The resident, who was also a dialysis patient, experienced a 6.25% weight loss in one month, dropping from 155.1 lbs to 144.7 lbs. Despite facility policy requiring notification and intervention for significant weight changes, there was no evidence that a reweigh was performed or that the provider was notified after the weight loss was identified. The resident had a history of hospitalizations for falls, fractures, and failure to thrive, and had a physician's order for a mechanical soft diet with nectar thick liquids. Progress notes indicated ongoing refusal of meals, and concerns about declining health and dietary intake were communicated by the dialysis center. Staff interviews revealed that the facility had not had a Registered Dietitian since March, relying instead on a corporate dietician as needed. The dialysis center's RD and team attempted to contact the facility for three weeks regarding the resident's weight loss, but reported poor communication and lack of updates on the resident's condition. The Nurse Practitioner was unaware of the resident's weight loss until contacted by the dialysis center, and stated that she would have expected immediate notification. The Assistant Director of Nursing acknowledged that no reweigh was obtained and could not provide evidence of provider notification.
Failure to Provide Adequate Pain Management Due to Medication Order Error
Penalty
Summary
A resident with diagnoses including left knee osteomyelitis and a sacral pressure ulcer was admitted to the facility following a hospital stay, with a pain management plan that included hydromorphone 4 mg every 4 hours for moderate to severe pain and an additional dose for breakthrough pain. Upon admission, physician orders were written for hydromorphone 4 mg every 4 hours PRN and another for every 24 hours PRN. However, the order for every 4 hours PRN was discontinued the following day, leaving only the once-daily PRN order in place. The resident subsequently experienced severe pain, requested additional pain medication, and was informed by staff that the medication was not due. The resident then called 911 and was transferred to the hospital for pain management. Record review and staff interviews revealed that the discontinuation of the every 4 hours PRN hydromorphone order was done in error, and nursing staff were unaware of the reason for the discontinuation. The nurse did not contact the on-call provider to address the resident's pain prior to the resident's transfer to the hospital. The Nurse Practitioner confirmed that both orders should have been in place and that timely administration of the medication could have better controlled the resident's pain. The Assistant Director of Nursing Services acknowledged the error in discontinuing the order and was unaware if the nurse attempted to contact the provider before the resident left the facility.
Failure to Communicate Significant Changes to Dialysis Center
Penalty
Summary
The facility failed to ensure appropriate communication and coordination of care for a resident requiring dialysis services. The resident, who had diagnoses including end stage renal disease and failure to thrive, experienced a significant weight loss of 6.25% (9.7 pounds) in one month and had an unwitnessed fall. Despite these significant changes in condition, there was no evidence in the communication binder, communication sheets, or medical record that these events were communicated to the dialysis center, as required by facility policy. The policy specifically states that any change of condition, including weight changes and falls, must be documented and communicated prior to dialysis treatment. Staff at the dialysis center reported that they had been attempting to contact the facility for three weeks regarding the resident's weight loss, and noted severe malnutrition and muscle wasting that had worsened since the last treatment. The communication sheets reviewed for the relevant months only indicated "routine dialysis" and did not include information about the resident's weight loss or fall. The Director of Nursing Services confirmed that there was no documentation of these communications, indicating a failure to follow established protocols for sharing critical health information with the dialysis provider.
Resident Injury Due to Improper Use of Shower Chair on Incline
Penalty
Summary
A resident with a history of falls and fractures, who was dependent on staff for showers and required assistance from two staff members for transfers, sustained a fall with injury during a shower. The incident occurred when a nursing assistant attempted to pull the resident, seated in a shower chair, backwards up a pronounced incline into the shower stall. As the chair was pulled over the incline, the front wheels lifted off the ground, causing the chair to tip backwards. The staff member was unable to stabilize the resident due to the resident's weight, resulting in the resident being lowered to the ground as the back of the chair broke. The resident subsequently complained of pain and was found to have fractured ribs, requiring admission to the Trauma Intensive Care Unit. Surveyor observation confirmed that the entrance to the shower stall had a steep incline, and review of the shower chair manufacturer's manual indicated that the equipment should not be used on an incline and all casters should remain in contact with the floor. Staff interviews revealed that only one staff member was present during the transfer into the shower stall, despite the resident's care plan requiring two-person assistance. The facility's investigation and staff statements corroborated that improper use of the shower chair and inadequate supervision contributed to the accident, resulting in significant injury to the resident.
Failure to Label and Date Food Items
Penalty
Summary
The facility failed to ensure that food was stored and distributed in accordance with professional standards for food service safety. During a surveyor's initial tour of the main kitchen's walk-in coolers, it was observed that several food items, including turkey and cheese sandwiches, cooked sausage links, white cakes, a gelatinous yellow liquid, and American cheese, were not labeled or dated. Staff K, a cook present during the observation, acknowledged that these items should have been labeled and dated as per regulations. Further observations in the 2nd, 4th, and 5th floor kitchenettes revealed multiple containers of food without labels or dates, including chili, unidentified foods, crab salad, cut watermelon, and more. Staff members present during these observations, including a Certified Medication Technician, a Nursing Assistant, and the Administrator, acknowledged that the items should have been labeled, dated, or discarded according to facility policy. The Food Service Director also confirmed that all items should have been labeled, dated, or discarded as per regulations and facility policy.
Deficiencies in Fluid Management and Communication for Dialysis Residents
Penalty
Summary
The facility failed to ensure proper fluid management for residents requiring dialysis, as evidenced by the lack of documentation for fluid intake for two residents. Resident ID #42, diagnosed with end-stage renal disease, had a physician's order for a 1200 mL fluid restriction per day, but there was no evidence of fluid consumption documentation. Similarly, Resident ID #51, dependent on renal dialysis, had a 1500 mL fluid restriction order, yet the facility did not document the resident's fluid intake. Interviews with nursing staff and the Assistant Director of Nursing revealed that the facility lacked a system for tracking fluid intake, and the documentation by nursing assistants did not include fluid intake records. The facility also failed to communicate critical information to the dialysis center for residents undergoing dialysis. Resident ID #42, who attended dialysis three times a week, frequently refused medications, and had an unwitnessed fall, but these incidents were not communicated to the dialysis center as required by facility policy. Similarly, Resident ID #79, who also attended dialysis, experienced a fall, but the dialysis center was not notified. Interviews with nursing staff and the Director of Nursing Services confirmed the lack of communication with the dialysis center regarding medication refusals and falls, despite the facility's policy requiring such notifications. The deficiencies highlight a systemic issue in the facility's adherence to its own policies regarding fluid management and communication with dialysis centers. The lack of documentation and communication could potentially impact the care and safety of residents requiring dialysis, as critical information was not being shared with the dialysis centers responsible for their treatment. The facility's failure to follow its policies was acknowledged by the Director of Nursing Services, who admitted unawareness of the requirement to notify the dialysis center of falls and medication refusals.
Failure to Conduct Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to conduct annual performance reviews for nurse aides, as required, for six staff members. Personnel records for Staff E, F, G, H, I, and J did not contain evidence of completed performance evaluations within the last 12 months. Staff E was hired in March 2015, Staff F in November 2011, Staff G in August 2022, Staff H in February 2020, Staff I in August 2023, and Staff J in October 2023. During an interview, the Director of Nursing Services was unable to provide documentation of these evaluations, confirming the deficiency in maintaining up-to-date performance reviews for these nurse aides.
QAPI/QAA Committee Attendance Deficiency
Penalty
Summary
The facility failed to ensure that the Quality Assurance Performance Improvement/Quality Assessment and Assurance (QAPI/QAA) committee included the required members and met the necessary attendance requirements. The committee is mandated to have, at a minimum, the Director of Nursing Services (DNS), the Medical Director, the Infection Preventionist, and at least three other facility staff members. However, record reviews revealed that the Infection Preventionist did not attend the meeting on April 11, 2024. Furthermore, both the Infection Preventionist and the DNS were absent from the meetings on October 15, 2024, and January 15, 2025. During an interview on March 13, 2025, the Administrator was unable to provide evidence of the attendance of the Infection Preventionist and DNS at these meetings.
Failure to Maintain Resident Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical records, as evidenced by the presence of a Survey History Binder in the main lobby area. This binder contained copies of previous surveys, including resident and staff rosters with identifying information of residents. The surveyor observed this binder on 3/12/2025, and it included details from multiple survey dates, identifying a total of 21 residents. During an interview, the Administrator was unable to provide evidence that the facility had protected the identifying information of these residents, leading to a deficiency in maintaining privacy and confidentiality.
Failure to Administer G-tube Feeding and Flush as Ordered
Penalty
Summary
The facility failed to ensure that a resident receiving continuous feeding via a gastrostomy tube (G-tube) was provided with the appropriate treatment and services to prevent complications. The resident, who was readmitted to the facility with a diagnosis including gastrostomy status, was observed to be receiving Jevity 1.2 cal at an incorrect rate of 60 mL/hr instead of the ordered 75 mL/hr. Additionally, the water flush rate was incorrectly set at 350 mL per shift instead of the prescribed 235 mL. During the surveyor's observation, the water flush bag was found empty, the tubing door to the feeding tube pump was open, and the screen was flashing a visible alarm. Interviews with the Registered Nurse and the Director of Nursing Services confirmed the discrepancies in the administration of the G-tube feeding and flush. The Nurse Practitioner also expressed the expectation that the G-tube feeding and flush should be administered at the ordered rate. These observations and interviews highlight the facility's failure to adhere to the physician's orders for the resident's G-tube feeding and water flush, potentially compromising the resident's nutritional and hydration status.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to ensure that the medical care of a resident, identified as Resident ID #28, was supervised by a physician following a significant weight loss. The resident, who was readmitted to the facility with diagnoses including dementia and dysphagia, experienced an 8.87% weight loss over 30 days and a 13.14% weight loss over six months. Despite the facility's policy requiring notification of the interdisciplinary team, dietician, physician, and family in cases of significant weight changes, there was no evidence that the physician or nurse practitioner was informed of the resident's weight loss. Interviews conducted during the survey revealed that the Director of Nursing Services expected the dietician to notify the physician or nurse practitioner of such significant weight changes. However, the resident's nurse practitioner confirmed that he was not aware of the weight loss and expected to be notified by the facility dietitian. This lack of communication and failure to follow the facility's policy resulted in the deficiency noted in the report.
Failure to Document and Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for two residents regarding enhanced barrier precautions (EBP). Resident ID #13 was admitted with a diagnosis including congestive heart failure and had a physician's order for EBP due to wounds. The order was documented as completed in the Medication Administration Record (MAR) even after the wound resolved, and no signage was observed outside the resident's room indicating EBP status. The Director of Nursing Services (DNS) acknowledged that the EBP order should have been discontinued or marked as not applicable once the wound resolved. Resident ID #217, with a history of Methicillin Resistant Staphylococcus Aureus (MRSA), had physician's orders for EBP, which were signed off as completed in the MAR. However, surveyor observations revealed no EBP signage or personal protective equipment (PPE) outside the resident's room. A registered nurse confirmed that the resident was not on EBP despite the existing order. The DNS expected EBP signage and a PPE bin to be present outside the resident's room, and for nurses to verify these before signing off the order in the MAR.
Failure to Implement Enhanced Barrier Precautions for Resident with MRSA
Penalty
Summary
The facility failed to maintain an infection prevention and control program to prevent the transmission of communicable diseases and infections, specifically regarding enhanced barrier precautions (EBP) for a resident with a history of Methicillin-Resistant Staphylococcus Aureus (MRSA). The facility's policy required the use of gowns and gloves during high-contact resident care activities for residents with multidrug-resistant organisms, and signage indicating the need for EBP was to be posted outside the resident's room. However, surveyor observations on multiple dates revealed that there was no signage posted outside the resident's room, and the required personal protective equipment (PPE) was not available outside the room. The resident in question was admitted to the facility with a diagnosis that included a personal history of MRSA. A physician's order dated shortly after admission required EBP due to this history. Despite the order being documented as completed in the Medication Administration Record, staff interviews confirmed that the EBP was not being followed. Both a registered nurse and the infection preventionist acknowledged the lack of compliance with the physician's order for EBP, as there was no signage or PPE available as required by the facility's policy.
Medication Error with Levothyroxine Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of Levothyroxine. The resident, who was readmitted to the facility in January 2025 with a diagnosis including cerebral infarction, had a physician's order for Levothyroxine Sodium oral tablet, 100 micrograms (MCG) once daily for thyroid disease. On January 24, 2025, a Nurse Practitioner reviewed the resident's laboratory results and obtained a new order to decrease the Levothyroxine dosage to 87.5 MCG, with a follow-up lab check in six weeks. However, the Medication Administration Record (MAR) for January 2025 showed that both the 87.5 MCG and 100 MCG doses were administered together, resulting in a total dose of 187.5 MCG on multiple consecutive days. Interviews with facility staff, including a Registered Nurse, the Nurse Practitioner, and the Director of Nursing Services, confirmed the error. The staff acknowledged that the resident received the incorrect total dosage of Levothyroxine from January 25 to January 29, 2025, contrary to the updated order. The facility was unaware of this medication error until it was identified by the surveyor during the investigation.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from significant medication errors. A resident, admitted with diagnoses including nontraumatic subarachnoid hemorrhage and essential hypertension, had a physician's order for Nimodipine 30 MG to be administered every 4 hours. However, the resident missed multiple doses on several occasions in January 2025 due to the facility waiting for pharmacy delivery and the resident's refusal of the medication. Specifically, the resident missed 6 doses on January 2, 5 doses on January 3, and several other doses on different dates throughout the month. The facility did not document notifying the provider about the missed doses or the resident's refusal of the medication. Interviews with the Director of Nursing and the Advanced Practice Registered Nurse revealed that the facility had issues obtaining the medication due to pharmacy approval, and some medications had to be brought in from home. The Medical Director was unaware of the specific medications or the duration of the unavailability. The lack of communication and documentation regarding the medication unavailability and resident refusals contributed to the deficiency.
Medication Error: Incorrect Insulin Administered
Penalty
Summary
The facility failed to ensure that residents are free from significant medication errors, specifically involving the administration of insulin. A surveyor observed an LPN administering 8 units of Insulin Lispro to a resident without an active physician's order. The resident, who has a diagnosis of diabetes, was supposed to receive Novolog, not Insulin Lispro, as per the current medication orders. The LPN mistakenly believed that Insulin Lispro and Novolog were the same and administered the wrong insulin, which had been discontinued on 12/21/2024. The Director of Nursing Services confirmed that there was no order for Insulin Lispro on the date of administration. The resident's physician clarified that although both insulins are fast-acting, they have different chemical structures and should not be interchanged. The error occurred because the LPN did not find the prescribed insulin in the medication cart and instead used a discontinued bottle from the medication refrigerator. This error had the potential to place the resident at risk for serious injury, impairment, harm, or death.
Deficiency in Facility-Wide Assessment Documentation
Penalty
Summary
The facility failed to document all required components of the facility-wide assessment, specifically in developing and maintaining a plan to maximize recruitment and retention of direct care staff. This deficiency was identified during a review of the facility's document titled 'Facility Assessment,' which was reviewed and approved on August 7, 2024. The absence of a comprehensive plan for staff recruitment and retention was confirmed during an interview with the Administrator on January 3, 2025, who acknowledged the oversight in the facility's assessment process.
Incomplete Medical Records for Insulin Administration
Penalty
Summary
The facility failed to maintain complete medical records in accordance with professional standards for a resident with diabetes who required insulin administration. The resident had a physician's order for NovoLog insulin to be administered based on a blood sugar sliding scale, with instructions to contact the provider if blood sugar levels exceeded 351 mg/dL. On two occasions, the resident's blood sugar levels were recorded as 395 mg/dL and 442 mg/dL, but there was no documentation that the provider was contacted as required by the physician's order. Interviews with two LPNs revealed that they did not document contacting the provider in the resident's medical record, despite the elevated blood sugar readings. The Director of Nursing Services was unable to provide evidence that the resident's medical record was complete and in accordance with professional standards and practices. This lack of documentation and communication with the provider constitutes a deficiency in maintaining accurate and complete medical records for the resident's care.
Improper Insulin Administration Using Syringe Instead of Pen Needle
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding the administration of insulin using an insulin pen injector. The resident, who was admitted with a diagnosis of diabetes, had a physician's order for Lantus SoloStar insulin pen-injector to administer 10 units subcutaneously in the morning. However, during a surveyor observation, it was noted that an LPN, identified as Staff B, did not use the insulin pen needle applicator as required. Instead, she drew the insulin from the pen using an insulin syringe, which is not in accordance with the physician's order or the facility's clinical competency guidelines. Upon further investigation, Staff B revealed that the insulin pen needle applicators were not available on the unit, leading her to use an insulin syringe to obtain the insulin from the pen. This practice was confirmed to have occurred on multiple occasions. During interviews with the unit Supervisor, Registered Nurse, and the Director of Nursing Services, it was acknowledged that the correct procedure was not followed, and the insulin pen needle applicator should have been used as per the physician's order.
Failure to Supervise Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision for a cognitively impaired resident, leading to an elopement incident. The resident, who had a history of mild neurocognitive disorder and other medical conditions, was found missing from the facility on the afternoon of October 7, 2024. Despite being equipped with a wander guard system, the facility did not notice the resident's absence until approximately six hours later, at 8:45 PM, when a medication technician discovered the resident was not in their room. The facility initiated their elopement policy at that time, but the police were not notified until 11:05 PM. The resident was eventually found by the Woonsocket police at a coffee shop, approximately 13.2 miles from the facility, and was taken to Landmark Hospital for evaluation. The resident was confused and admitted to smoking marijuana, and the family confirmed the resident's poor memory. The resident was discharged back to the facility without any acute medical treatment. Upon the resident's return, the facility failed to implement any safety measures or conduct an elopement assessment, as required by their policy, to ensure the resident's well-being. Interviews with facility staff and the resident's family revealed a lack of communication and understanding of the situation. The facility's administration initially claimed the resident was on a Leave of Absence (LOA), despite not having an order for such and failing to document it in the LOA log. The facility's failure to recognize the incident as an elopement and to follow their own policies placed the resident at risk for harm, as no interventions were implemented to prevent future occurrences.
Failure to Adhere to Wound Care Protocols for Resident with Burns
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for a resident with burns. The resident was admitted with a history of dementia, muscle wasting, and surgical aftercare following a procedure for burns, which included wound debridement and an allograft to the left thigh. Despite the hospital's continuity of care form indicating these conditions, the facility's initial Weekly Skin Audit did not document the burn and allograft. Furthermore, a non-pressure wound evaluation also failed to note the burn and allograft. A burn clinic later recommended daily wet to dry dressing treatment for the resident's left hip, but this recommendation was not reviewed or acted upon by the facility for eight days until the surveyor's intervention. Additionally, the resident had four blistered areas on the right foot, which were not covered and were in different stages of healing. These blisters were documented in the initial Weekly Skin Audit but were not mentioned in a subsequent audit. During the survey, the LPN caring for the resident was unaware of the burn clinic's treatment recommendation and the blisters on the right foot. The facility's wound nurse and nurse practitioner acknowledged the oversight, with the nurse practitioner agreeing with the burn clinic's recommendations and expecting treatment for the blisters. The Director of Nursing Services also acknowledged the inaccuracies in the skin assessments and the lack of follow-up on the burn clinic's recommendations.
Failure to Provide Treatment for Pressure Ulcer
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with a pressure ulcer, as required by professional standards of practice. The deficiency was identified through surveyor observation, record review, and interviews with staff. The resident, who was admitted with a pressure injury to the right knee, did not receive appropriate assessment and treatment as per the facility's policy. The initial skin audit did not include necessary details such as measurement, stage, and appearance of the wound, and there was no evidence of a treatment order for the pressure injury. Further investigation revealed that the facility's contracted wound physician recommended a specific treatment for the pressure ulcer, but this recommendation was not acted upon for 18 days. During this period, the resident's pressure injury remained untreated, and the wound was observed to be open to air, causing pain to the resident. The LPN caring for the resident was unaware of the pressure injury and the recommended treatment, indicating a lack of communication and follow-up on the physician's orders. Interviews with the wound nurse and the Director of Nursing Services confirmed that there was no treatment in place for the pressure injury until it was brought to their attention by the surveyor. The facility's failure to implement and monitor appropriate interventions for the resident's pressure ulcer led to a deficiency in care, as the resident did not receive the necessary treatment to promote healing and prevent further complications.
Significant Medication Error Due to Improper Resident Identification
Penalty
Summary
The facility failed to keep residents free from significant medication errors, as evidenced by the case of a resident who received Suboxone in error. The resident, who was admitted with diagnoses including multiple myeloma, atrial fibrillation, and chronic obstructive pulmonary disease, was mistakenly given Suboxone, a medication not prescribed for them. This error was reported to the Rhode Island Department of Health following a community complaint. The facility's policy on medication administration requires verification of the medication order against the MAR and confirmation of the resident's identity, which was not followed in this instance. The error occurred when an LPN removed Suboxone from the medication cart and administered it to the wrong resident. The Unit Manager confirmed that the medication was intended for another resident. The Director of Nursing Services acknowledged the error and indicated that the LPN failed to properly identify the resident before administering the medication. This incident highlights a significant lapse in the facility's medication administration procedures, leading to a serious medication error.
Food Storage and Safety Compliance Issues Identified
Penalty
Summary
The facility was found to have deficiencies related to food storage and serving practices as well as staff compliance with food safety regulations during a survey conducted from 4/1/2024 to 4/4/2024. Observations revealed that cold food items in dining locations were being served at temperatures above the acceptable range, with examples such as tuna salad sandwiches at 51.2 degrees F and ham on a Chef Salad plate at 55.2 degrees F. Additionally, food items in refrigerators lacked proper labeling, including a brown paper bag and containers without product labels, and some items were being stored past their manufacturer's use by date, such as Dannon Light +Fit yogurt with a use by date of 3/11/2024. Furthermore, staff members in the main kitchen were observed not wearing proper hair restraints and beard coverings as required by the Rhode Island Food Code 2018 Edition. Instances included a dietary aide serving food with a hair net only covering the back of her head, leaving the front unrestrained, and staff members in the main kitchen not wearing beard nets while performing food preparation and dishwashing tasks.
Failure to Maintain Infection Control for CPAP/BIPAP Devices
Penalty
Summary
The facility failed to maintain an infection prevention and control program for residents using CPAP and BIPAP devices. Specifically, the facility did not adhere to its own policy for cleaning and disinfecting these devices. Resident ID #5, who was readmitted with sleep apnea and COPD, had no evidence of their BIPAP machine being cleaned in March or April 2024. Similarly, Resident ID #21, readmitted with obstructive sleep apnea and COPD, also had no evidence of their CPAP machine being cleaned during the same period. Resident ID #38, who was readmitted with obstructive sleep apnea and COPD, had a BIPAP machine that was not cleaned in March or April 2024, despite being used on several occasions. Interviews with the Infection Preventionist and the Director of Nursing Services confirmed that the facility did not have orders to clean the machines and could not provide evidence that the machines were cleaned according to the facility policy. This lack of adherence to the cleaning protocol for CPAP and BIPAP devices indicates a failure to maintain a sanitary environment and prevent infections, as required by the facility's infection prevention and control program.
Failure to Obtain Required Laboratory Services
Penalty
Summary
The facility failed to obtain laboratory services to meet the needs of its residents, specifically for a resident prescribed Depakote. The resident, admitted in April 2023 with diagnoses including bipolar disorder and violent behaviors, had a new order dated 3/5/2024 to check the valproic acid level in 2 weeks, which should have been drawn on 3/18/2024. Record review revealed no evidence that the lab was obtained as ordered. During interviews, the LPN, Physician, and Director of Nursing Services all acknowledged that the valproic acid level was not obtained per the physician's orders.
Deficiency in Nurse Competency for Glucagon Administration
Penalty
Summary
The facility failed to ensure that licensed nurses had the appropriate competencies and skills to provide necessary nursing services, specifically in the administration of Glucagon for a resident with diabetes. The deficiency was identified when a resident experienced an unresponsive episode due to critically low blood sugar levels. During the incident, a Registered Nurse, Staff B, administered only sterile water instead of the reconstituted Glucagon because she was unaware of the need to reconstitute the medication. This error was discovered by another nurse, Staff C, who administered the correct dose after realizing the mistake. Further investigation revealed that Staff B had not received any training or competency assessments related to the reconstitution and administration of Glucagon. Additionally, personnel records for other nursing staff, including Staff A, D, E, and F, also lacked evidence of such competencies. The Director of Nursing Services confirmed the absence of training and competencies for these staff members, which contributed to the deficiency in providing safe and effective care for residents with metabolic disorders like diabetes.
Medication Errors Lead to Resident's Hypoglycemic Episode
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically concerning the administration of insulin to a diabetic resident. The resident, who was admitted for short-term rehabilitation, had physician orders to hold insulin administration if their blood sugar was less than 200 mg/dl. However, the resident received insulin on multiple occasions when their blood sugar was below this threshold, leading to a critical low blood sugar event. On one occasion, the resident's blood sugar was 138 mg/dl, yet they were administered 40 units of Aspart insulin, contrary to the physician's orders. The resident experienced a severe hypoglycemic episode, becoming unresponsive with a blood sugar level of 31 mg/dl. Emergency measures were taken, including the administration of Glucagon and calling 911. However, the initial dose of Glucagon was not properly reconstituted, resulting in the resident only receiving sterile water. This error was identified during the emergency response, and a second dose of properly reconstituted Glucagon was administered. The resident required additional medical interventions, including intravenous Dextrose and supplemental oxygen, before being transported to the hospital. Interviews with staff revealed a lack of awareness and training regarding the insulin administration parameters and the proper preparation of Glucagon. Staff members admitted to not seeing the full medication orders on their screens and were unaware of the need to hover over the orders to view them in their entirety. The Director of Nursing Services acknowledged the errors and the lack of evidence that the resident was kept free from significant medication errors, highlighting deficiencies in staff training and medication administration procedures.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
