Cedar Haven Operations Llc Dba Lake Forrest Health
Inspection history, citations, penalties and survey trends for this long-term care facility in Smithfield, Rhode Island.
- Location
- 180 Log Road, Smithfield, Rhode Island 02917
- CMS Provider Number
- 415049
- Inspections on file
- 45
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 18 (2 serious)
Citation history
Health deficiencies cited at Cedar Haven Operations Llc Dba Lake Forrest Health during CMS and state inspections, most recent first.
A resident with dysphagia, autonomic dysfunction, seizure disorder, a G-tube, and dependence on staff for feeding had physician orders and a care plan requiring a minced and moist diet with thin liquids given by spoon only while upright. Video from a room camera showed a nurse providing thin liquids through a straw while the resident was lying down and continuing despite the resident coughing. Additionally, a physician ordered every-shift monitoring and documentation of vital signs, including lung sounds, O2 saturation, temperature, and signs of aspiration for seven days, but the MAR showed that required vital signs were not obtained on multiple shifts. The DON confirmed these deviations from physician orders and expected practice.
A resident with altered mental status and seizures was not treated with dignity when a nursing assistant commented on their odor in their presence and later covered the resident's consented video monitoring device with a pillow. The DON confirmed these actions and could not provide evidence that the resident's rights to respect and electronic monitoring were upheld.
A resident with a gastrostomy, requiring Enhanced Barrier Precautions (EBP), received care from two nursing assistants who did not wear gowns as mandated by facility policy. Despite clear signage and staff awareness of EBP requirements, video evidence and staff interviews confirmed non-compliance with gown use during high-contact care activities. The DON could not provide documentation of an effective infection control program related to EBP for this resident.
A resident with multiple chronic conditions was administered a combination of medications, including Schedule II narcotics, intended for another resident after a CMT became distracted and confused medication cups. The medications had been pre-poured by an RN and given to the CMT to administer, which was outside the CMT's scope of practice. The resident became unresponsive and required emergency intervention and hospital transfer due to the medication error.
A resident with multiple chronic conditions was hospitalized after being mistakenly given a combination of antipsychotics, antidiabetic agents, benzodiazepines, and narcotics intended for another resident. The error occurred when a medication aide, distracted during medication pass, administered the wrong medications, including Schedule II controlled substances, resulting in the resident becoming unresponsive and requiring emergency interventions such as Narcan and hospitalization.
A nursing assistant made inappropriate sexual comments and exposed her chest to a resident with a history of mental health conditions but intact cognition. The incident was witnessed and reported by another NA, and both staff statements confirmed the event. The facility failed to provide evidence that the resident was protected from sexual abuse as required by policy.
A facility failed to follow a physician's orders for a resident with multiple health conditions, including congestive heart failure and COPD, by not obtaining weekly weights as directed. The deficiency was confirmed during an interview with the DON, who acknowledged the oversight.
A resident with HIV did not receive their prescribed medication, BIKTARVY, for four days due to an alleged agreement for the family to provide it, which was undocumented. Staff interviews confirmed the missed doses and lack of documentation, while the resident was aware of the importance of not missing the medication.
A resident with a gastrostomy tube was administered Isosource 1.5 Cal nutritional formula without a current physician's order, following the discontinuation of the order. Despite the lack of a valid order, the resident continued to receive the formula at 60 ml/hour, as confirmed by an LPN and the DON, who could not provide an explanation for the discontinuation.
A resident receiving nutrition via a G-tube was documented as receiving Nutren 2.0 and Two Cal HN 2.0 formulas, despite these not being available in the facility. Instead, the resident was administered Isosource 1.5 Cal. Staff interviews confirmed the inaccurate documentation and unavailability of the prescribed formulas.
A resident with a history of atherosclerosis and dementia experienced ongoing left leg pain and swelling. Despite a physician's order for an orthopedic consult, the resident refused the initial appointment, and the facility failed to reschedule it or address the pain effectively. Staff interviews revealed a lack of communication and follow-up, leading to the resident's continued discomfort.
The facility failed to maintain effective infection control, particularly in using Enhanced Barrier Precautions (EBP) and Covid-19 protocols. Staff did not consistently wear required PPE during high-contact care for residents needing EBP, and Covid-19 positive residents were not adequately protected as staff entered rooms without proper PPE and neglected hand hygiene. Interviews confirmed these lapses, indicating systemic issues in infection control practices.
The facility failed to provide care in accordance with professional standards for two residents. One resident, with a hip fracture, did not have a physician's order for toe touch weight bearing, leading to independent ambulation without restrictions. Another resident, with schizoaffective disorder, refused an antipsychotic injection twice, and staff failed to notify the provider or reschedule the medication. Staff interviews revealed a lack of awareness and communication regarding these care needs.
A resident with opioid dependence did not receive Lorazepam as ordered due to a failure in medication delivery and administration. Despite the medication being available in the facility's pyxis machine, the resident missed five doses. Staff interviews revealed that the medication should have been administered immediately, and the delay was not communicated to the appropriate personnel.
A resident with moderately impaired cognition and a history of falls was not provided with the required frequent safety checks, leading to a fall and hip fracture. Despite the care plan indicating the need for checks every 20-30 minutes, staff were unaware of this requirement, and there was no documentation to ensure compliance.
A resident with severe cognitive impairment entered another resident's room and physically assaulted them by grabbing their neck. Staff intervened to separate the residents, but the incident was reported as a failure to protect residents from abuse. Both residents have severe cognitive impairments, and the event was acknowledged by the facility's Director of Nursing Services.
Two residents experienced communication difficulties with a non-English speaking NA, impacting their ability to convey needs for ADLs. Both residents have intact cognition and require extensive assistance. The NA, who works the 3:00 PM to 11:00 PM shift, confirmed her inability to understand English, and the facility's administrator acknowledged this language barrier.
The facility failed to support resident choice in shower preferences for two residents. One resident, with intact cognition, reported not receiving showers as per their preference, and records showed no evidence of showers in the last 30 days. Another resident, with severely impaired cognition, reported only two showers in six months, with no evidence of showers in the last 30 days. The administrator could not provide evidence of compliance with the residents' preferences.
A resident with dementia and cognitive impairment eloped from a facility due to inadequate supervision and incomplete wandering risk assessment. Despite being at moderate risk for wandering, necessary interventions were not implemented. The resident, requiring supervision while smoking, was not monitored outside the smoking area, leading to their unsupervised exit. They were found by police in the roadway, confused and wearing heavy clothing, highlighting the facility's failure to ensure safety.
A resident with severe cognitive impairment was sexually abused by another resident with a history of inappropriate behavior. Despite previous incidents, the facility failed to update the care plan or notify the physician, leading to the resident being left unsupervised and vulnerable. Staff interviews revealed that the resident was often left unsupervised in the victim's room, contributing to the incident.
The facility failed to provide a consistent activities program for residents on the North B Unit, resulting in residents being left alone or wandering without engagement. Scheduled activities were not held, and there was no activities calendar available. Residents with Alzheimer's and other conditions were observed without participation in group or one-on-one activities, despite care plans indicating the need for structured engagement. Staff interviews revealed a lack of awareness and insufficient staffing for activities, particularly on weekends.
The facility failed to provide adequate care and timely interventions for two residents. One resident experienced severe edema and wound issues without proper notification or intervention, leading to a hospital admission for DVT and paracentesis. Another resident had unresponsive incidents that were not reported to the provider, resulting in a lack of necessary assessments and interventions. The facility also failed to obtain an admission weight and address a fall incident appropriately.
The facility failed to maintain a sanitary and comfortable environment, with surveyors observing stained and odorous bathrooms across all units. Staff interviews confirmed the persistent issues, and a change in cleaning products was noted as ineffective. Additionally, the flooring and carpets were in poor condition, requiring repair or replacement.
Failure to Follow Physician Orders for Dysphagia Management and Vital Sign Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of practice and followed physician orders for a resident with significant swallowing difficulties and other complex medical conditions. The resident, admitted with diagnoses including seizure disorder, autonomic dysfunction, presence of a gastrostomy tube, bilateral upper extremity contractures, and dysphagia, was dependent on staff for eating. A physician’s order dated 1/6/2026 specified a house diet with minced and moist texture and thin liquids to be provided by spoon only. The care plan initiated on 12/4/2024 also identified swallowing difficulty and included an intervention to provide thin liquids via spoon. A community complaint and video footage from the resident’s room showed that during an overnight shift, a nurse gave the resident a drink using a straw while the resident was lying down and continued to provide liquids while the resident was coughing, contrary to the physician’s order and care plan. The DON confirmed, after reviewing the video, that the nurse provided thin liquids with a straw while the resident was not upright and continued despite the resident’s coughing. The facility also failed to follow a physician’s order related to monitoring for possible aspiration. A physician’s order dated 3/19/2026 directed staff to obtain and document the resident’s vital signs, including lung sounds, oxygen saturation, temperature, and signs and symptoms of aspiration such as coughing or runny nose, every shift for seven days. Review of the March 2026 Medication Administration Record showed that vital signs were not obtained during the 3:00 PM–11:00 PM and 11:00 PM–7:00 AM shifts on 3/23/2026, and the 11:00 PM–7:00 AM shift on 3/24/2026. In an interview, the DON stated she expected vital signs to be obtained and documented each shift as ordered and acknowledged that the facility failed to ensure physician orders were followed for this resident.
Failure to Honor Resident Dignity and Electronic Monitoring Rights
Penalty
Summary
A deficiency was identified when a nursing assistant (NA) failed to treat a resident with respect and dignity during care. The NA was observed and acknowledged making a comment about the resident's odor within earshot of the resident, who was able to understand and respond to yes/no questions. This action was captured on video surveillance footage provided by the resident's family. The facility's policies require that all residents be treated with respect and dignity, and the Director of Nursing Services (DNS) was unable to provide evidence that the resident was treated appropriately in this instance. Additionally, the same NA was observed on video covering the resident's electronic monitoring camera with a pillow, despite the resident having provided consent for video surveillance and appropriate signage being posted in the room. The DNS confirmed that the NA covered the camera and could not provide evidence that the resident's right to use electronic monitoring equipment was respected. The resident involved had diagnoses including altered mental status and seizures and had been admitted to the facility several months prior to the incident.
Failure to Follow Enhanced Barrier Precautions for Resident with Gastrostomy
Penalty
Summary
The facility failed to maintain an infection prevention and control program as required, specifically regarding the use of Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy. Facility policy mandates the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices or wounds. Despite signage indicating EBP requirements in the resident's room, video surveillance footage on two separate dates showed that two nursing assistants provided morning care to the resident without wearing gowns, as required by policy. Interviews with the Infection Preventionist and the nursing assistants confirmed that the resident had been on EBP since admission and that staff were aware of the requirement to wear gowns and gloves during care. However, both nursing assistants acknowledged not wearing gowns during the observed care episodes. The Director of Nursing Services was unable to provide evidence that the facility maintained an infection control program to prevent the spread of infection related to EBP for this resident.
Significant Medication Error Due to Incompetent Medication Administration and Protocol Breaches
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets to provide safe nursing and related services, as evidenced by a significant medication error involving a resident. A Certified Medication Technician (CMT) administered a cup of medications intended for another resident, which included multiple drugs such as Schedule II narcotics, anticonvulsants, antidiabetics, and other medications. This error occurred after the CMT became distracted during the medication pass, placed the wrong medication cup in the cart, and subsequently administered it to the wrong resident. The medications had been pre-poured by a Registered Nurse (RN), who also provided the narcotics to the CMT for administration, despite this being outside the CMT's scope of practice. The resident who received the incorrect medications had a medical history including heart failure, intellectual disabilities, and chronic obstructive pulmonary disease. Following administration of the wrong medications, the resident was found lethargic, unresponsive, and with pinpoint pupils. Emergency intervention was required, including the administration of Narcan and transfer to the hospital, where the resident received activated charcoal for overdose treatment. Interviews with staff revealed that the RN had signed out and prepared narcotics for one resident and gave them to the CMT to administer, which was not in accordance with scope-of-practice regulations. The CMT acknowledged being distracted and administering the wrong medications, including narcotics, to the resident. The Director of Nursing confirmed that the RN should not have delegated the administration of narcotics to the CMT and that medications should not have been pre-poured and left in the medication cart. These failures in following established medication administration protocols and scope-of-practice requirements resulted in a significant medication error and placed the resident in immediate jeopardy.
Resident Hospitalized After Receiving Another Resident's Medications
Penalty
Summary
A significant medication error occurred when a certified medication staff member, while distracted during the morning medication pass, administered a set of medications intended for one resident to another resident. The medications included antipsychotics, antidiabetic agents, benzodiazepines, narcotics, and other drugs, some of which were Schedule II controlled substances that medication aides are not permitted to administer according to state regulations. The error was facilitated by the nurse providing narcotics to the medication aide to administer, and by the medication aide pre-pouring and leaving the medications unattended in the medication cart. The resident who received the incorrect medications had a medical history including heart failure, intellectual disabilities, and chronic obstructive pulmonary disease. After receiving the wrong medications, the resident was found lethargic, unresponsive, and with pinpoint pupils. Emergency interventions were required, including the administration of two doses of Narcan, EMS transport, and subsequent hospitalization. The resident also received activated charcoal in the emergency room due to the overdose. Facility records and staff interviews confirmed that the medication aide signed off the administration of the medications in the wrong resident's Medication Administration Record (MAR). The nurse involved acknowledged giving the narcotics to the medication aide, and both staff members confirmed the sequence of events that led to the error. The Director of Nursing Services also acknowledged that the resident received another resident's medications, resulting in the need for emergency medical treatment and hospital admission for overdose.
Failure to Protect Resident from Sexual Abuse by Nursing Assistant
Penalty
Summary
A nursing assistant (NA), identified as Staff C, engaged in inappropriate conduct with a resident who had a history of bipolar disorder, anxiety, and adjustment disorder, but was assessed as cognitively intact with a BIMS score of 15. Staff C entered the resident's room, initiated conversation by complimenting the resident's appearance, and then lifted her own shirt to expose her chest while wearing a sports bra, stating that she too was 'sexy.' This incident was directly witnessed by another NA, Staff D, who immediately reported the behavior to the Director of Nursing Services (DNS). The facility's abuse prohibition policy defines sexual abuse as any non-consensual sexual contact, including unwanted intimate touching or exposure, regardless of the resident's cognitive status. The resident involved did not recall the incident during a surveyor interview, but statements from both Staff C and Staff D confirmed the inappropriate exposure and comments. The facility's investigation documented the sequence of events and the resident's reaction, but there was no evidence provided that the facility ensured the resident was kept free from sexual abuse as required by policy.
Failure to Follow Physician's Orders for Resident Weights
Penalty
Summary
The facility failed to meet professional standards of quality by not following a physician's orders for a resident who was readmitted with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, and acute kidney failure. The physician had ordered weekly weights to be obtained starting on March 8, 2025. However, a review of the resident's electronic medical record and progress notes revealed that the weights were not recorded on March 8, 2025, or March 15, 2025, as ordered. This deficiency was identified during a surveyor interview with the Director of Nursing Services, who acknowledged that the weights were not completed as required.
Failure to Administer HIV Medication as Prescribed
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Bictegravir-Emtricitabine-Tenofovir (BIKTARVY), a medication prescribed for HIV treatment. The resident, who was admitted in March 2025 with diagnoses including HIV and dialysis dependence, did not receive the prescribed medication on four consecutive days. The Electronic Medication Administration Record (EMAR) for March 2025 showed no evidence of administration on the specified dates. Nursing progress notes indicated that the medication was expected to be brought in by the resident's family, and a filled prescription was available at the community pharmacy. Interviews with staff and the resident revealed that the medication was not administered due to an alleged agreement for the family to provide it, which was not documented. The resident was aware of the missed doses and had informed the facility of the importance of not missing the medication. Staff members, including the Registered Nurse, LPN, Administrator, and Director of Nursing Services, acknowledged the missed doses and the lack of evidence for the agreement. The Medical Director was informed of the initial unavailability but was unaware of the continued missed doses.
Failure to Follow Physician's Orders for G-tube Nutrition
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 nutrition via a gastrostomy tube (G-tube). The resident, who was admitted with diagnoses including protein-calorie malnutrition, dysphagia, and a gastrostomy tube, had a physician's order for Isosource 1.5 Cal nutritional formula to be administered four times a day, which was discontinued on December 23, 2024. However, the resident continued to receive the Isosource 1.5 Cal without a current physician's order on multiple occasions after the discontinue date. Surveyor observations and staff interviews revealed that the resident was administered Isosource 1.5 Cal at 60 ml/hour without a valid physician's order. Staff A, a Licensed Practical Nurse, confirmed the administration of the formula and was unable to provide evidence of a current physician's order. The Director of Nursing Services also acknowledged the lack of a physician's order and could not explain why the order was discontinued. This deficiency highlights a failure in following physician's orders and ensuring proper documentation for the resident's nutritional care.
Inaccurate Documentation of G-tube Nutrition Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident receiving nutrition via a gastrostomy tube. The resident was admitted with diagnoses including protein-calorie malnutrition, dysphagia, and a gastrostomy tube. Physician's orders were in place for Nutren 2.0 and Two Cal HN 2.0 formulas to be administered via the G-tube. However, the Medication Administration Record (MAR) inaccurately documented that these formulas were administered, despite their unavailability in the facility. During a surveyor observation, it was noted that the resident was being administered Isosource 1.5 Cal instead of the prescribed formulas. Staff interviews revealed that the facility did not have the Nutren 2.0 or Two Cal HN formulas available, and the resident had been receiving Isosource 1.5 Cal since admission. The Administrator and Director of Nursing Services acknowledged the discrepancy, confirming that the orders were signed off inaccurately and the prescribed formulas were not available at the facility prior to the observation.
Failure to Provide Timely Orthopedic Care
Penalty
Summary
The facility failed to ensure that a resident received timely treatment and care in accordance with professional standards of practice. The resident, who was admitted in July 2023 with diagnoses including atherosclerosis of bilateral legs and dementia, had a physician's order for an orthopedic consult due to chronic bilateral knee pain. Despite the resident's complaints of left leg pain and swelling, and a scheduled orthopedic appointment on December 4, 2023, the resident refused to attend the appointment. The facility did not reschedule the appointment or address the ongoing pain effectively, as evidenced by continued complaints of pain and swelling in the resident's left leg. Interviews with staff revealed a lack of communication and follow-up regarding the resident's condition. The LPN acknowledged the resident's pain regimen was ineffective, and the Nurse Practitioner was unaware of the resident's continued pain after the missed appointment. The Director of Nursing Services confirmed the resident's refusal to attend the initial appointment but did not ensure a rescheduled appointment until it was brought to their attention by the surveyor. This lack of timely intervention and communication resulted in the resident experiencing ongoing pain and discomfort.
Infection Control Deficiencies in PPE Usage and Covid-19 Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for several residents. Surveyor observations revealed that staff did not adhere to the required use of personal protective equipment (PPE) such as gowns and gloves during high-contact care activities for residents with conditions necessitating EBP. For instance, a nursing assistant was observed transferring a resident with wounds without wearing a gown, despite the resident being on EBP. Additionally, there was a lack of EBP signage and PPE supplies at the doors of residents who required such precautions, indicating a systemic issue in implementing EBP protocols. Further deficiencies were noted in the facility's handling of Covid-19 precautions. Residents who tested positive for Covid-19 were not adequately protected as staff failed to don the necessary PPE, including gowns, gloves, and face shields, when entering their rooms. This was observed when a certified medication technician entered a Covid-19 positive resident's room without the required PPE and failed to perform hand hygiene, subsequently delivering trays to other residents. Similarly, laundry staff entered another Covid-19 positive resident's room without PPE and did not perform hand hygiene, citing language barriers as a reason for not understanding the posted precautions. Interviews with staff, including the Infection Preventionist and the Director of Nursing Services, confirmed that the expected protocols were not followed. They acknowledged that staff should have worn the appropriate PPE and performed hand hygiene as per the facility's signage and infection control policies. The lack of adherence to these protocols highlights significant lapses in the facility's infection prevention and control measures, particularly in the context of EBP and Covid-19 precautions.
Failure to Ensure Professional Standards of Care
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. For Resident ID #21, who was admitted with mantle cell lymphoma and anxiety disorder, the facility did not have a physician's order for toe touch weight bearing status after the resident suffered a fall resulting in a left hip fracture. Despite recommendations from the hospital and physical therapy for toe touch weight bearing, the resident was found to be ambulating independently, and staff were unaware of the weight bearing restrictions. This lack of communication and documentation led to the resident not receiving the appropriate care as per the hospital's recommendations. For Resident ID #35, who was admitted with schizoaffective disorder and dementia, the facility failed to follow its medication administration policy. The resident had a physician's order for Invega Sustenna, an antipsychotic medication, to be administered every 28 days. However, the resident refused the medication on two occasions, and there was no evidence that the staff notified the provider or attempted to reschedule the injection. The staff's failure to communicate the refusals to the provider or nursing management resulted in the resident not receiving the necessary medication as prescribed. Interviews with staff, including nursing assistants, LPNs, and the Director of Nursing Services, revealed a lack of awareness and communication regarding the residents' care needs and medication refusals. The Nurse Practitioner also confirmed that she was not informed of the hospital's recommendations or the medication refusals, which would have prompted her to take further action. These deficiencies highlight a breakdown in communication and adherence to professional standards of practice within the facility.
Failure to Administer Lorazepam as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Lorazepam. The resident, who was admitted with a diagnosis including opioid dependence, had a physician's order for Lorazepam to be administered twice daily for seven days. However, the medication was not administered as ordered on two occasions due to it not being delivered by the pharmacy. This resulted in the resident missing five doses of Lorazepam. Interviews with staff revealed that the medication was available in the facility's pyxis machine, an automated medication dispensing system, and most nurses had access to it. The Licensed Practical Nurse who entered the order and the Director of Nursing Services both acknowledged that the medication should have been administered immediately. The Nurse Practitioner also expected the medication to be started on the day it was ordered and to be notified if it was unavailable. Despite these expectations, the resident did not receive the medication until four days after it was ordered.
Failure to Provide Adequate Supervision for Resident at Risk of Falls
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for a resident who required frequent safety checks. The resident, admitted in June 2024 with diagnoses including mantle cell lymphoma and anxiety disorder, was found to have moderately impaired cognition. On 9/18/2024, the resident fell in their room and was sent to the emergency room, later returning to the facility with a left hip fracture. The resident's care plan indicated a risk for falls due to weakness and pain, with an intervention for frequent safety checks due to impulsivity. However, staff interviews revealed that the resident was not on frequent safety checks as required by the care plan. The Director of Nursing Services acknowledged the need for frequent safety checks every 20-30 minutes but could not explain why staff were unaware of this requirement. Additionally, there was no documentation to confirm that safety checks were being conducted, and the Director of Nursing Services did not expect staff to document these checks. This lack of awareness and documentation contributed to the failure in providing the necessary supervision to prevent the resident's fall and subsequent injury.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving two residents. Resident ID #2, who has severe cognitive impairment and a history of dementia with psychotic disturbance, entered the room of Resident ID #1, who also has severe cognitive impairment and a history of Alzheimer's disease. Despite being told to leave, Resident ID #2 grabbed Resident ID #1 by the neck. Staff members intervened to separate the residents, but the incident highlights a failure to prevent physical abuse. The incident was reported to the Rhode Island Department of Health, and staff statements corroborated the event. A housekeeper witnessed the altercation and called for assistance, while a nursing assistant and a nurse responded to separate the residents. The Director of Nursing Services acknowledged the occurrence of the incident. Despite the intervention, the facility's inability to prevent the altercation constitutes a deficiency in protecting residents from abuse.
Language Barrier in Resident Care
Penalty
Summary
The facility failed to provide an environment that promotes the maintenance or enhancement of the quality of life for residents whose primary language is not the dominant language of the staff providing care. Specifically, two residents, identified as Resident ID #1 and Resident ID #2, were unable to effectively communicate their needs to a Nursing Assistant (NA) on the 3:00 PM to 11:00 PM shift, who does not speak English. Resident ID #1, who has intact cognition and is totally dependent on staff for transfers and requires extensive assistance for activities of daily living (ADLs), expressed difficulty in communicating with the NA due to the language barrier. Similarly, Resident ID #2, who also has intact cognition and requires extensive assistance for ADLs, reported that the NA regularly assigned to their room attempts to communicate using signs and gestures, which is ineffective. During interviews, the NA, identified as Staff A, confirmed her inability to understand English, especially when spoken quickly, and was only able to respond to questions when asked in French. The facility's administrator acknowledged that Staff A is a full-time employee who does not speak English, which further substantiates the communication barrier experienced by the residents.
Failure to Support Resident Choice in Shower Preferences
Penalty
Summary
The facility failed to promote and facilitate resident self-determination through support of resident choice regarding weekly showers for two residents. Resident ID #1, who was readmitted in June 2023 with diagnoses including dysphagia, contractures, and anarthria, was found to have an intact cognition with a BIMS score of 15 out of 15. Despite being totally dependent on staff for transfers and requiring extensive assistance for bathing, the resident reported not receiving morning care or showers as per their preference. The resident's care plan indicated that showers were very important, yet there was no evidence of showers being provided in the last 30 days. Similarly, Resident ID #3, readmitted in September 2020 with diagnoses of muscle weakness, unsteadiness, and major depressive disorder, had a severely impaired cognition with a BIMS score of 6 out of 15. Despite this, the resident was interviewable and reported having only two showers in the last six months. The facility's records failed to show evidence of showers being provided in the last 30 days, and the administrator could not provide evidence of compliance with the residents' shower preferences.
Resident Elopement Due to Inadequate Supervision and Incomplete Risk Assessment
Penalty
Summary
The facility failed to ensure adequate supervision and interventions for a resident identified as a moderate risk for wandering, leading to an elopement incident. The resident, who was admitted with diagnoses including dementia, Wernicke's encephalopathy, and traumatic brain injury, was assessed to have moderately impaired cognition. Despite being at a moderate risk for wandering, the facility did not implement necessary interventions such as the application of a wanderguard or frequent checks. Additionally, a subsequent wandering risk assessment was incomplete, failing to accurately assess the resident's cognitive orientation and medication use, which would have maintained the resident's moderate risk status. On the day of the incident, the resident was last seen by staff at approximately 9:00 AM sitting outside the facility. The resident, who required supervision while smoking due to cognitive loss, was not adequately monitored when not in the designated smoking area. The smoking attendant confirmed that she did not supervise residents outside the smoking area, and the Assistant Director of Nursing stated that residents assessed as wander risks should be accompanied to and from the smoking area. However, the facility did not ensure this protocol was followed, resulting in the resident eloping from the facility. The resident was found by a police officer after being reported by a community member as confused and laying in the roadway. The resident was transported to the hospital, where it was noted that they were wearing unseasonably heavy clothing and were unsure of their location or what had happened. The facility's failure to provide adequate supervision and complete the wandering risk assessment accurately placed the resident at risk for harm, as evidenced by the unsupervised exit and subsequent discovery on the roadway.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident involving two residents with severely impaired cognition. Resident ID #1, who has aphasia, Alzheimer's disease, and dementia, was found in a vulnerable situation with Resident ID #2, who has major depressive disorder with severe psychotic disorder, anxiety disorder, and insomnia. Both residents reside on a secured unit and have a BIMS score of 0, indicating severely impaired cognition. The incident occurred when a nursing assistant observed Resident ID #2 stroking Resident ID #1's genitalia, with Resident ID #1 unable to consent due to cognitive impairment. Prior to the incident, there were multiple instances of inappropriate behavior by Resident ID #2 that were not adequately addressed by the facility. These included an attempt to kiss the Assistant Director of Nursing Services and previous incidents of inappropriate behavior towards staff and other residents. Despite these behaviors, there was no evidence that the physician was notified or that Resident ID #2's care plan was updated to include interventions to mitigate or monitor such behaviors. The facility's inaction in addressing Resident ID #2's inappropriate behaviors and failure to update the care plan contributed to the incident of sexual abuse. Staff interviews revealed that Resident ID #2 was often left unsupervised in Resident ID #1's room, despite previous combative behavior when asked to leave. The lack of intervention and monitoring placed Resident ID #1 and other cognitively impaired residents at risk for harm.
Failure to Provide Adequate Activities Program
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the needs and preferences of residents on the North B Unit, a secured/locked unit. The surveyor's observations and interviews revealed that scheduled activities were not consistently held, and there was no evidence of an activities calendar being available or posted for residents. The Director of Recreation provided a monthly activities calendar upon request, but several scheduled activities, such as Afternoon Devotionals and Friday Flicks, did not occur as planned. Resident ID #7, who has Alzheimer's disease, major depressive disorder, and anxiety disorder, was observed multiple times sitting alone or falling asleep in the activity/dining room without participating in any group or one-on-one activities. The resident's care plan included structured activities like walking outside and reading, but these were not offered. Similarly, Resident ID #4, with dementia and anxiety disorder, was observed alone in their room without engagement in activities, despite their care plan emphasizing the importance of socialization and exercise. Resident ID #6, with Alzheimer's disease and vascular dementia, was also observed alone or wandering without participating in activities, despite their care plan's focus on simple, structured activities. Additionally, Resident ID #5, with Alzheimer's disease and major depressive disorder, lacked a social care plan and was observed pacing and standing alone. Interviews with staff revealed a lack of awareness of the activities calendar and insufficient staffing to provide activities, particularly on weekends, leading to residents wandering more frequently.
Failure to Provide Adequate Care and Timely Interventions
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards for two residents, leading to significant deficiencies. Resident ID #1, who was on hospice care with chronic pain and pancreatic cancer, experienced fluctuating and severe edema in the lower extremities, which was not adequately addressed by the facility staff. Despite assessments indicating 4+ pitting edema, no interventions or orders were implemented, and the provider was not notified of the resident's increasing edema and pain. The resident eventually requested to go to the hospital, where an acute DVT was diagnosed. Additionally, the resident's abdominal girth was not measured as ordered due to the unavailability of a measuring tape, and the resident was admitted to the hospital for a paracentesis procedure. Further deficiencies were noted in the management of Resident ID #1's wounds. An open area on the resident's right lower extremity was identified but not reported to the provider, and no new interventions or orders were implemented. The wound nurse was not made aware of the new wounds until several days later, and the resident experienced significant pain during wound care. Additionally, the resident experienced a fall, but there was no evidence of an assessment or notification to the physician, nor were any interventions put in place to prevent future falls. The facility also failed to obtain an admission weight for the resident as ordered. Resident ID #2, who had dementia and type two diabetes mellitus, experienced two unresponsive incidents that were not properly addressed. On both occasions, the provider was not notified, and no interventions were implemented. The Nurse Practitioner was unaware of these incidents and indicated that an assessment and lab orders would have been conducted if informed. The facility staff failed to alert the on-call provider when the Nurse Practitioner did not return the call, leading to a lack of appropriate response to the resident's change in condition.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility was found to have failed in maintaining a safe, sanitary, and comfortable environment for residents, staff, and the public across all four units observed. Surveyor observations revealed that multiple bathrooms, including those in resident rooms, staff areas, and public spaces, had heavy accumulations of yellow and brown stains in the toilet bowls, accompanied by a strong odor of urine. These conditions were corroborated by interviews with various staff members, including registered nurses, nursing assistants, and housekeepers, who confirmed the persistent presence of stains and odors over several months. The housekeepers noted a change in cleaning products from Clorox bleach to Ecolab 73 Disinfecting Acid Bathroom Cleaner, which they reported as ineffective in removing the stains. Additionally, the surveyors observed that the flooring throughout the facility, including resident rooms, hallways, and office areas, was scuffed, and the carpets were heavily stained. The facility's Administrator acknowledged the need for repair or replacement of the flooring. These findings were based on community complaints submitted to the Rhode Island Department of Health, which alleged issues with cleanliness and sanitation, contributing to an uncomfortable environment. The facility's leadership, including the Director of Nursing Services and the Administrator, acknowledged the deficiencies observed by the surveyors.
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The facility failed to follow physician orders for post-fall care for three anticoagulated residents who experienced falls. One resident on a blood thinner with a head injury was ordered to be transferred to the ED after a telehealth evaluation, but an LPN did not send the resident, citing instructions to contact a supervisor first and inability to reach that supervisor. For two other residents on anticoagulants, providers ordered intensive neuro checks (every 15 minutes, then every 30 minutes, then hourly, then every 4 hours), but staff instead performed neuro checks only once per shift for 72 hours. The DON and Medical Director acknowledged that the transfer and monitoring orders were not implemented as written.
A resident with intact cognition and psychiatric diagnoses sustained a left eyebrow laceration when another resident with a documented history of escalating aggressive and threatening behaviors struck them with a cane during a hallway dispute. The aggressive resident had multiple prior documented incidents, including verbal threats to kill others, attacking a roommate with a cane over TV volume, throwing objects during activities, and throwing a lunch plate at staff. Despite these events, the care plan was not updated with interventions to address physical aggression toward other residents, and a psychiatric recommendation for PRN trazodone for agitation, anxiety, and insomnia was only implemented as PRN for insomnia. The failure to assess, monitor, and implement effective interventions for the aggressive resident’s behaviors led to the assault and injury and, per the report, placed this and other residents at risk of serious physical and psychosocial harm.
A resident with impulse disorder, mood and anxiety diagnoses, and a history of escalating verbal and physical aggression had multiple documented incidents of threats, object throwing, and assault with a cane. Despite a psychiatric consult recommending PRN trazodone for agitation, anxiety, and insomnia, the provider order listed insomnia only, and the care plan was not updated with specific interventions to address the resident’s physically aggressive behaviors after several documented events. Subsequently, the resident struck another resident with a cane, causing a facial laceration that required wound closure and ongoing treatment.
The facility failed to properly screen and document clearance for a NA with disqualifying criminal history information before hire, as required by its abuse, neglect, and exploitation policy. A BCI check showed disqualifying information, yet the NA was hired, completed orientation, and worked independently based only on verbal disclosure of an old drug-related charge, without written details or verification. Later, a staff member reported witnessing this NA grab a resident’s face and kiss the resident on the lips, and a community complaint alleged inappropriate interactions with the same resident, prompting involvement of local police.
A resident with anxiety disorder and PTSD was unable to attend meals and activities with peers because the facility lost the resident's clothing after it was sent to laundry. The resident was observed in a hospital gown with only a few clothing items in the room, and the record lacked an admission inventory of belongings. The DON/Administrator reported that laundry was handled by an outside vendor without a tracking system or item documentation.
A resident with dementia and severely impaired cognition was subjected to repeated non-consensual kissing on the lips by an NA, who entered the resident’s room during care, verbally expressed affection, and then kissed the resident on the mouth on at least two separate occasions witnessed by staff. One staff member delayed reporting the first incident due to fear of the NA. These actions occurred despite a facility policy defining sexual abuse as any non-consensual sexual act and requiring protections of residents’ rights and well-being.
Failure to investigate allegations of resident-to-resident sexual inappropriateness: A resident with dementia and TBI was documented as being inappropriate with another resident, and psych notes later described increased sexually inappropriate behaviors toward other residents. Staff interviews showed the resident had been observed touching others and needing frequent redirection, but the DON, ADON, and Administrator acknowledged the facility did not complete an investigation or recognize the allegation as possible abuse.
A resident with dementia and a hearing deficit did not receive ear care as ordered because the chart lacked the Debrox order and the ear was flushed before the intended Debrox course was completed. In a separate incident, staff witnessed inappropriate kissing of a resident with dementia, but the allegation was not reported to the provider and the care plan was not updated. A third resident’s wound care was also not completed as ordered when an RN used normal saline instead of the prescribed Vashe wound wash.
A resident with migraines and chronic pain did not receive timely pain management after repeatedly reporting a migraine and appearing in visible distress. An NA notified an LPN, an RN said she could not access the med cart, and the resident continued waiting while the LPN was off the unit; the PRN migraine medication was not given until 40 minutes after the first complaint. The DON acknowledged the resident should not have waited that long for pain medication.
A resident missed 6 doses of a prescribed antibiotic, and the MAR did not show that the provider was notified. The RN acknowledged the missed doses and said they should have been reported, while the Medical Director stated she was unaware of the missed doses and would have extended the antibiotic course if informed. The DON also confirmed the missed doses and expected provider notification for any missed antibiotic dose.
Failure to Follow Post-Fall Physician Orders for Anticoagulated Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement physician orders for post-fall care, including hospital transfer and neurological monitoring, for residents on anticoagulant therapy. One resident with atrial fibrillation on Xarelto experienced an unwitnessed fall with a scalp laceration and head lump. The on-call provider, after a telehealth evaluation, ordered transfer to the ED and wrote an order directing that the resident be sent to the hospital. The resident was not transferred as ordered, and an additional order for vital signs and neuro checks every shift for 72 hours after the fall was not completed as ordered on one of the shifts. The LPN caring for this resident stated she did not send the resident to the ED because she had been instructed to call a supervisor before sending residents out, and she was unable to reach the supervisor during the shift. A second resident, also with atrial fibrillation and on Xarelto, had an unwitnessed fall with injury. The on-call provider was notified and ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, then every four hours for an additional 24 hours. A physician’s order reflecting this schedule was scanned into the EMR. However, the neuro checks were not completed as ordered; instead, they were performed only once per shift for 72 hours. The RN who authored the progress note documented the fall and the resident’s anticoagulant use, and later stated she could not remember why she did not transcribe and complete the neuro checks as ordered. A third resident with atrial fibrillation on Apixaban had a non-injury fall after attempting to walk independently. The on-call provider ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, and then every four hours for an additional 24 hours, and this order was scanned into the EMR. The record did not show that these neuro checks were completed as ordered; instead, neuro checks were documented only once per shift for 72 hours. The Medical Director stated he would have expected the first resident to be transferred to the ED as ordered and that the facility should not override a provider’s order. The DON acknowledged that the transfer order and the ordered monitoring for the first resident were not followed as written, and that for the second and third residents, staff performed only once-per-shift neuro checks instead of the more frequent monitoring ordered by the providers.
Failure to Manage Escalating Aggression Leading to Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident, Resident ID #1, from abuse by another resident with a known history of escalating aggression, Resident ID #2. Resident ID #1 was admitted in October 2025 with diagnoses including paranoid schizophrenia and adjustment disorder with mixed anxiety and depressed mood, and had a BIMS score of 14/15, indicating intact cognition. On 4/27/2026, progress notes documented that Resident ID #1 was on the receiving end of a physical altercation with another resident and was found with a deep bleeding abrasion to the left eyebrow. A subsequent nursing note described a new laceration to the left eyebrow measuring 0.5 cm by 2.0 cm by 0.1 cm, related to a resident-to-resident incident, for which wound closure strips were applied. Resident ID #1 requested police involvement and a police report, and refused transfer to the hospital for sutures. Resident ID #2 had been admitted in December 2024 with multiple psychiatric and behavioral diagnoses, including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed a BIMS score of 13/15 and documented both physical and verbal behaviors during the look-back period. Progress notes over several months recorded a pattern of escalating aggressive and threatening behaviors: on 9/13/2025, Resident ID #2 threatened to slit another resident’s throat and made additional threats toward staff; on 11/7/2025, the resident was involved in a verbal dispute with raised voice, name-calling, and verbal threats; on 12/28/2025, after another resident struck Resident ID #2 with a helmet, Resident ID #2 was overheard threatening to kill that resident if touched again. On 2/21/2026, the on-call provider documented that Resident ID #2 attacked a roommate with a cane over TV volume and required ER transfer for psychiatric evaluation. Subsequent notes on 3/9/2026 and 4/10/2026 described the resident throwing poker chips on the floor, yelling and swearing at staff and residents, and throwing a lunch plate across the nurses’ station at a nursing assistant due to dissatisfaction with portion size. Despite this documented pattern, the care plan for Resident ID #2, dated 1/16/2025, only indicated a behavior problem of being verbally aggressive toward staff with resident-to-resident altercations on 12/28/2025, 2/21/2026, and 4/27/2026, and record review failed to show added interventions to mitigate the risk of physical aggression toward other residents after the 2/21/2026 cane attack and the object-throwing incidents on 3/9/2026 and 4/10/2026. A psychiatric evaluation on 4/23/2026 recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order entered on 4/24/2026 specified trazodone 25 mg twice daily as needed only for insomnia, and record review did not show that agitation and anxiety were included as indications for use. During interviews, the RNP and the DON stated it was their expectation that agitation and anxiety would have been included in the trazodone order, and the DON was unable to provide evidence that the care plan had been updated with interventions to address Resident ID #2’s physically aggressive behaviors documented on 2/21/2026, 3/9/2026, and 4/10/2026. On 4/27/2026, the DON documented that Resident ID #2 was ambulating down the hall toward his/her room while Resident ID #1 was walking in the opposite direction, and the two residents began a verbal dispute. Before staff could intervene, Resident ID #2 used his/her cane to make contact with Resident ID #1, resulting in the eyebrow laceration that required steri-strips and ongoing wound treatment. A police incident report recorded that Resident ID #1 stated being struck with a walking cane, wanted to press charges, and that Resident ID #2 admitted to striking Resident ID #1, leading to an arrest on one count of felony assault with a dangerous weapon. The facility’s failure to assess, monitor, and implement effective interventions for Resident ID #2’s known and escalating aggressive behaviors, including failure to update the care plan after prior incidents and failure to fully implement psychiatric recommendations, resulted in this resident-to-resident altercation and injury, and the report states that this failure placed Resident ID #1 and other residents at risk of serious physical and psychosocial harm.
Failure to Implement Psychiatric Recommendations and Update Behavior Care Plan Leading to Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health services and care planning for a resident with a documented history of psychiatric conditions and aggressive behaviors. The resident was admitted in December 2024 with diagnoses including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed intact cognition with a BIMS score of 13/15 and documented physical and verbal behaviors during the look-back period. Over time, multiple behavioral incidents were recorded, including threats to slit another resident’s throat during a smoking session, verbal disputes with name-calling and threats, and a statement to another resident that if touched again the resident would be killed. Further documentation showed escalating behaviors, including an incident where the resident attacked a roommate with a cane over television volume and required ER transfer for psychiatric evaluation, throwing poker chips and yelling when not winning at Bingo, causing the roommate to avoid the shared bathroom due to inappropriate comments and frustration over the light being turned on at night, and throwing a lunch plate across the nurses’ station at a nursing assistant over portion size. The care plan, initiated in January 2025 for verbal aggression and resident-to-resident altercations, did not contain added interventions to address the resident’s physically aggressive behaviors toward others after the incidents on 2/21/2026, 3/9/2026, and 4/10/2026. The DNS later could not provide evidence that the care plan had been updated with interventions to mitigate the risk of these physically aggressive behaviors or to guide staff in ensuring the safety of other residents. On 4/23/2026, a psychiatric evaluation recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order dated 4/24/2026 implemented trazodone 25 mg twice daily as needed for insomnia only, and the record lacked evidence that agitation and anxiety were included as indications for use as recommended by the consulting psychiatrist. Both the RNP and the DNS stated it was their expectation that the trazodone order would have included agitation and anxiety. Following this incomplete implementation of the psychiatric recommendation and the lack of updated behavioral interventions in the care plan, a resident-to-resident altercation occurred on 4/27/2026 in which the resident struck another resident with a cane, causing a laceration to the left eyebrow that required closure with steri-strips and ongoing wound treatment.
Failure to Properly Screen and Clear NA with Disqualifying Criminal History
Penalty
Summary
The facility failed to ensure that a prospective employee was properly screened and cleared for a history of abuse, neglect, exploitation, or misappropriation of resident property before hire. A nursing assistant, identified as Staff A, was hired on 11/18/2025 and was working independently as a NA. Prior to hire, a Bureau of Criminal Identification (BCI) check dated 11/6/2025 showed that Staff A had disqualifying information under federal and state law. Surveyor review after discovery of the positive BCI revealed that Staff A had an extensive criminal history. Despite this, the facility proceeded with the hire and allowed Staff A to complete orientation and work independently without obtaining or maintaining documentation specifying the nature of the disqualifying information, contrary to the facility’s Abuse, Neglect and Exploitation Policy, which requires screening and documentation of proof that such screening occurred. Subsequently, a facility-reported incident submitted on 4/17/2026 documented that a staff member reported witnessing Staff A grab a resident’s face and kiss the resident on the lips. A community-reported complaint submitted on 4/22/2026 alleged inappropriate interactions between the same NA and the same resident, and included a local police incident report indicating the resident’s family intended to pursue charges related to the incident. During interviews, the Human Resource Director stated that Staff A had disclosed disqualifying information related to a prior drug-related charge from about ten years earlier, but acknowledged there was no documentation specifying the nature of the disqualifying information and that this was known only by word of mouth. The Administrator stated she was aware that the BCI contained disqualifying information and that she exercised her own judgment in proceeding with the hire, and further acknowledged she did not receive documentation detailing the disqualifying information until it was brought to her attention by the surveyor.
Failure to Maintain Resident Clothing and Dignity
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity when the resident was unable to attend meals and activities with other residents because of a lack of appropriate clothing. The resident was admitted in May 2025 with diagnoses including anxiety disorder and post-traumatic stress disorder, and a care plan revised on 8/25/2025 described the resident as highly social and willing to participate in a variety of activities, with an intervention to provide reminders of scheduled events. During observation on 4/29/2026, the resident was found in the room wearing a hospital gown while other residents were in the dining room for lunch. Only one pair of pants and two T-shirts were observed in the room. The resident stated that the facility lost all of the resident's clothing, including shirts, pants, shorts, and socks, after they were sent to laundry services several months earlier and were never returned. The resident reported that the Administrator was told about the missing clothing, but no follow-up occurred and the clothing was neither located nor replaced. The record did not contain an admission inventory list of the resident's belongings, and the Administrator stated that laundry was handled by an outsourced company without a tracking system or documentation identifying which items belonged to which resident.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse when a nursing assistant (NA) was observed kissing the resident on the lips on more than one occasion. The resident, identified as having dementia and a Brief Interview for Mental Status (BIMS) score of 0/15 indicating severely impaired cognition, had been admitted in March 2026. On one occasion, a Certified Medication Technician (CMT) reported that while she was assisting the resident with breakfast, the NA entered the room, verbally expressed affection for the resident, made a kissing noise, leaned forward, and kissed the resident on the lips. This incident made the CMT uncomfortable, and she later discussed it with another NA. A separate staff member, another NA, reported that two days earlier she had observed the same NA enter the resident’s room while morning care was being provided, ask the resident if they remembered her, state that she loved the resident, then lean toward the resident, make a kissing sound, and kiss the resident on the mouth with full lip-to-lip contact. This second NA did not report the incident at the time because she was fearful of the NA involved and only came forward after learning of the later incident. The facility’s abuse, neglect, and exploitation policy defined sexual abuse as a non-consensual sexual act of any type with a resident and required protections for each resident’s health, welfare, and rights, as well as screening of potential employees for a history of abuse. Despite this policy, the resident with severely impaired cognition was subjected to repeated non-consensual kissing by the NA.
Failure to Investigate Allegations of Resident-to-Resident Sexual Inappropriateness
Penalty
Summary
The facility failed to ensure that allegations made by residents were recognized as possible abuse by staff and that all allegations were investigated for Resident ID #41, who was admitted with diagnoses including dementia and traumatic brain injury. A facility policy titled, Abuse, Neglect and Exploitation, stated that an immediate investigation is warranted when suspicion of abuse, neglect, exploitation, or reports of abuse, neglect, or exploitation occur. A progress note written by an RN documented that a resident reported Resident ID #41 was being inappropriate with another resident. Subsequent records included psychiatric evaluations stating the resident was being seen due to increased sexually inappropriate behaviors toward other residents and that sexual impulses may present an unsafe environment for other patients in the facility. Staff interviews revealed that Resident ID #41 had been observed touching other residents' shoulders and hands and required frequent redirection. The RN who documented the incident stated the behavior involved an attempted hug without contact and that both residents were separated and assessed, while the ADON and DON acknowledged they were unaware of the behavior or that the facility had not investigated the allegations. The Administrator also acknowledged that an investigation had not been completed to determine what sexually inappropriate behavior had occurred and that staff did not identify the allegation as possible abuse or investigate it immediately.
Failure to Follow Orders, Report Abuse, and Perform Ordered Wound Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for a resident with dementia and anxiety disorder who had a hearing deficit and complained of right ear wax buildup. The medical record showed an order for Debrox ear drops and a separate order to flush the right ear with warm water two times a day following Debrox usage for 5 days, but the record did not include a physician order for the Debrox solution. The April 2026 MAR showed the resident’s right ear was flushed six times, and the resident stated that the right ear still felt blocked. The RN acknowledged flushing the ear and was unaware whether Debrox had been given, while the DON stated the order had been entered incorrectly and that the ear should not have been flushed before Debrox administration. The NP stated the intended order was for Debrox twice daily for five days before irrigation and that she would not have ordered daily ear flushing. The facility also failed to report an allegation of abuse and failed to update the care plan for a resident with dementia after staff reported inappropriate interactions with a nursing assistant. A community complaint and police incident report indicated the family wanted to press charges, and the Administrator and DON confirmed that staff had reported witnessing the nursing assistant kiss the resident on two occasions. The record did not show that the allegation was reported to the provider, and the comprehensive care plan was not updated to reflect the allegation or any interventions related to the incident. The NP stated she was unaware of the incident and would have expected to be notified, and the ADNS acknowledged that the provider had not been notified and the care plan had not been updated. The facility further failed to follow a wound care order for a resident readmitted with peripheral vascular disease and cellulitis of the lower limb. The physician ordered cleansing open areas on the left lower leg with Vashe wound wash, applying xeroform to the wound bed, and wrapping with kling. During observation, the RN performing wound care did not use Vashe wash and instead cleansed the wound with normal saline. The RN acknowledged using normal saline rather than the ordered cleanser, and the DON stated she would expect the nurse to follow the wound orders as written.
Delayed Pain Medication for Resident with Migraine
Penalty
Summary
Safe, appropriate pain management was not provided for Resident ID #17, who was admitted with diagnoses including migraines and chronic pain. The resident’s care plan dated 4/20/2026 included a goal for the resident to verbalize adequate pain relief and an intervention to respond immediately to any complaint of pain. The physician ordered Butalbital-APAP-Caffeine 50-300-40 mg, 1 capsule every 12 hours as needed for migraine pain. On 4/29/2026 at 10:30 AM, the resident was observed in the hallway complaining of a migraine, moaning in pain, and holding his/her head. At 10:34 AM, an NA reported to an LPN that the resident wanted pain medication, and at 10:37 AM the resident continued to complain of migraine pain and told an RN about the pain, but the RN stated she did not have keys to the medication cart and could not get any pain medication. The resident continued to complain of severe head pain, returned to the room to lie down at 10:40 AM, and the LPN was still off the unit at 10:42 AM. The resident was not assessed when the LPN returned, and the medication was not administered until 11:10 AM, 40 minutes after the initial complaint. The resident later reported pain rated 7 out of 10, and the DON acknowledged that a resident should not wait 40 minutes for pain medication.
Missed Antibiotic Doses Not Reported to Provider
Penalty
Summary
The facility failed to ensure that Resident ID #17 was free from significant medication errors when the resident missed 6 doses of a prescribed antibiotic. The resident was admitted in April 2026 with diagnoses including surgical aftercare and complication of surgical and medical care, and had a physician order dated 4/3/2026 for Cefadroxil 500 mg by mouth twice daily for 14 days. Review of the April 2026 MAR showed missed doses on 4/3 at 8:00 PM, 4/6 at 8:00 PM, 4/11 at 8:00 PM, 4/12 at 8:00 AM, 4/14 at 8:00 PM, and 4/17 at 8:00 AM. The record did not show that the provider was notified of the missed antibiotic doses. During interview, the RN acknowledged the 6 missed doses and stated they should have been reported to the provider. The Medical Director stated she was unaware of the missed doses and said she would have extended the antibiotic course if she had known. The DON also acknowledged the missed doses and stated she would expect the provider to be informed if a resident misses any dose of an antibiotic.
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