Grand Islander Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Middletown, Rhode Island.
- Location
- 333 Green End Avenue, Middletown, Rhode Island 02842
- CMS Provider Number
- 415034
- Inspections on file
- 27
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Grand Islander Center during CMS and state inspections, most recent first.
A resident with hyperosmolality and hypernatremia did not receive a repeat BMP as ordered by the provider. Record review showed the test was not completed on the scheduled date, and the DON confirmed the expectation that the order should have been followed.
A resident with a psychotic disorder did not receive medically related social services after being issued a 30-day discharge notice for non-payment. The resident subsequently displayed disruptive and self-injurious behaviors, including an incident involving a plastic bag, leading to hospital transfer. Documentation and interviews confirmed that the Social Worker did not engage with the resident or their family after the notice, and no support or case management was provided despite requests.
A resident with Parkinson's disease, assessed as needing two-person assistance with a gait belt for transfers, was routinely transferred by a single nursing assistant using a stand pivot transfer. This failure to follow the care plan led to the resident sustaining significant fractures to the left tibia and fibula, with staff and the resident confirming that transfers were often performed without the required assistance.
A resident with a history of skin cancer and recent MOHS surgery did not receive wound care as ordered by a dermatologist, including specific soaks and Manuka Honey applications. Facility records showed no evidence that these orders were implemented or verified by the facility physician, and the Administrator could not provide documentation to support that the orders were followed.
A resident with severe cognitive impairment, a history of falls, and a recent hip fracture was left to ambulate alone with a walker when a nursing assistant walked ahead, contrary to the care plan and PT recommendations requiring supervision or stand-by assistance. The resident let go of the walker, fell, and sustained a hip fracture. Staff interviews confirmed a misunderstanding of the resident's supervision needs, and there was no evidence that proper supervision was provided.
Two residents with complex care needs did not have comprehensive, person-centered care plans in place. One resident who suffered a fall with injury and required hospitalization did not have this event addressed in their care plan. Another resident with multiple mobility issues had conflicting instructions in their care plan regarding transfer devices, with no clear specification of the appropriate method. The DON was unable to provide documentation of accurate, individualized care plans for these residents.
A nursing assistant did not receive required Abuse Prohibition training upon hire, as revealed during an investigation into an alleged staff-to-resident abuse incident involving a resident with multiple sclerosis and rheumatoid arthritis who was cognitively intact. The DON confirmed that there was no documentation of the mandated training for the staff member.
Three residents with care plans requiring weekly skin assessments did not receive these assessments as scheduled. Documentation was missing for multiple weeks, and staff were unable to provide evidence that the assessments were completed, despite care plans specifying this intervention for residents with stroke and dementia diagnoses.
Nursing staff, including RNs and LPNs, did not complete required annual competencies and skill assessments, including IV therapy and PICC line management, as outlined in the facility assessment. Documentation confirming completion of these competencies was not available during surveyor review.
Surveyors found that medications were left unattended, not properly dated when opened, and expired or discontinued drugs were not discarded as required. Staff acknowledged that medications such as insulin pens, inhalers, and oral solutions were either expired, lacked opening dates, or were prescribed for residents no longer present, but remained in storage or on medication carts.
Surveyors found that the facility did not implement Enhanced Barrier Precautions (EBP) for two residents with wounds and one resident with a urinary catheter. Required EBP signage was missing from room doors, and staff were unaware of the need for EBP or PPE use during high-contact care activities, despite physician orders for wound and catheter care. The unit manager and clinical advisor confirmed these lapses, indicating a breakdown in infection control procedures and staff training.
Three residents with documented preferences for watching TV were unable to do so for several days due to a power outage affecting their room outlets. Despite their care plans and MDS assessments highlighting the importance of television as a preferred activity, no alternative means, such as tablets, were provided, leaving the residents without meaningful activities and causing dissatisfaction.
A resident with impaired mobility and a history of skin breakdown did not consistently receive preventative skin care or weekly skin assessments as required by their care plan. Staff failed to document or provide preventative skin care for most opportunities in a month, and weekly skin checks were not completed after the initial assessment. The resident developed pink, blanchable areas on the buttocks, and staff interviews confirmed the lack of adherence to the care plan.
A resident with multiple medical conditions experienced a significant weight loss over a short period, but the facility failed to implement nutritional interventions or notify the dietitian and physician as required by policy. Despite regular weight monitoring, the decline was not addressed, and key clinical staff were unaware of the extent of the weight loss.
A resident receiving IV antibiotics via a PICC line for enterococcal bacteremia did not have required documentation of external catheter length or upper arm circumference, as ordered by the physician. Nursing staff signed off on dressing changes that were not performed, and facility records lacked evidence of proper monitoring and documentation for the PICC line.
A resident requiring hemodialysis did not have a physician's order for routine monitoring of their dialysis access site for bruit and thrill, as required by facility policy and the care plan. Documentation showed that the last assessment was performed several months prior, and staff confirmed the absence of an order until the issue was identified by surveyors, resulting in a lapse in monitoring consistent with professional standards.
The facility did not ensure that provider review and action occurred on pharmacist-identified medication regimen irregularities for three residents, including recommendations regarding insulin and oral diabetes medication dosing, PRN lorazepam use, duplicate PRN orders, and clarification of acetaminophen and Miralax administration.
A resident with a history of atrial fibrillation and cardiac conditions did not receive prescribed doses of Warfarin on two consecutive days, as documented in the MAR. This omission was confirmed by staff and resulted in a subtherapeutic PT/INR level, indicating a significant medication error.
Surveyor observation of the dumpster area, with the Food Service Director present, found various discarded items such as cardboard boxes, used masks, bubble wrap, wood pieces, a mattress, and a metal bed frame scattered on the ground. The Maintenance Director acknowledged the need for cleanup and proper disposal of these items.
The facility did not follow its antibiotic stewardship protocols for two residents with indwelling catheters. In both cases, antibiotics were started without proper documentation of required clinical criteria or completion of an antibiotic time-out, and in one instance, a urine culture later showed no bacterial growth. Facility staff acknowledged these lapses and could not provide evidence that the stewardship program was followed.
A resident with a history of stroke experienced a fall resulting in a laceration that required sutures and transfer to an acute care hospital. Facility records did not show that the resident's representative was immediately notified of the incident and transfer, and staff could not provide evidence of timely notification, resulting in a deficiency.
The facility did not complete or document required neurological assessments for two residents after falls, including one with a head injury and another with dementia, despite facility policy and provider recommendations. The Assistant Director of Nursing confirmed the lack of documentation and incomplete evaluations.
A resident with serious medical conditions experienced significant weight fluctuations that were not properly addressed by the facility. Despite policies requiring re-weighing after significant weight changes, the resident was not re-weighed, and there was incomplete documentation of meal and snack intake. Staff interviews confirmed these deficiencies, and the dietitian was not informed of the weight loss, preventing timely nutritional intervention.
A resident with a DNR order passed away within 24 hours of admission, but staff performed CPR and used a defibrillator despite the resident's MOLST form indicating no resuscitation. The ADNS acknowledged the error in following the resident's wishes.
A resident with a Stage IV pressure injury did not receive complete wound care instructions as per professional standards. The physician's order lacked details on wound packing and location, despite being signed off as administered. The DON acknowledged the incomplete order during an interview.
A resident received unnecessary doses of Meropenem due to a transcription error. The resident, admitted with bacteremia and osteomyelitis, was prescribed 49 doses of the antibiotic. However, the resident received four additional doses beyond the prescribed amount. The DON acknowledged the error, attributing it to a nurse's incorrect transcription of missed doses, which led to the administration of extra doses.
Surveyors found deficiencies in food storage and labeling in the facility's main kitchen and kitchenettes. Unlabeled and expired food items, including hot dogs, yogurt, and milk, were observed, contrary to the facility's policy requiring labeling and timely disposal. The FSD and staff acknowledged these lapses.
The facility failed to provide routine dental services for two residents with cognitive impairments and dental issues, despite physician orders and evident dental needs. Observations confirmed missing and broken teeth, and staff interviews revealed no evidence of dental care being provided.
The facility failed to maintain proper infection control practices, particularly in the use of Enhanced Barrier Precautions (EBP) and during wound care. Staff were observed not wearing gowns during high-contact activities for residents with MDRO risks, and a nurse failed to perform hand hygiene during a wound dressing change. These actions were contrary to the facility's infection prevention protocols.
Two residents did not receive fortified diets as ordered by their physicians, despite being at nutritional risk. One resident with malnutrition and dysphagia was not given double protein portions and fortified foods, while another resident with dementia experienced significant weight loss without receiving the prescribed fortified diet. Staff interviews confirmed the failure to follow dietary orders.
A resident with sensorineural hearing loss did not receive proper assistance with hearing aids, as required by their care plan and physician's order. Despite a directive for daily application, the hearing aids were only applied once in May. Observations and interviews revealed that staff typically applied the aids only when the resident had visitors, contrary to the order. The DON acknowledged the oversight and expected daily application.
A resident with limited range of motion due to a stroke did not receive a prescribed ankle-foot orthosis (AFO) to assist with mobility. Despite a physician order and casting for the AFO, the device was not provided due to a lack of follow-up by Rehabilitation Services and missing physician authorization. Staff interviews revealed confusion about the process, resulting in the resident not receiving the necessary device.
A resident with muscle weakness and urinary incontinence experienced a deficiency in care when the facility failed to follow the bowel protocol for constipation. Despite having a care plan and physician's orders in place, the resident did not have a bowel movement for six days, and the protocol was not followed. Staff interviews revealed a lack of communication and understanding of the protocol, and the DON acknowledged the failure to initiate the protocol and notify a provider.
A resident with end-stage renal disease and hypertension did not receive appropriate dialysis care due to a lack of communication between the LTC facility and the dialysis center. Despite elevated blood pressure readings, the facility failed to follow up with the dialysis center or notify the physician after the dialysis center left the communication sheet blank. Interviews revealed inconsistencies in sending communication sheets, and the Director of Nursing could not provide evidence of effective communication or physician notification.
A resident with a history of stroke and mobility issues did not receive a required physical therapy evaluation, as identified in their care plan. Despite the resident's expressed need for more therapy and an Occupational Therapy screen requesting a PT evaluation, the facility failed to complete it. Interviews with the Director of Rehabilitation Services and the DON confirmed the expectation for the evaluation, but no evidence of its completion was found.
Failure to Complete Ordered Blood Work
Penalty
Summary
A deficiency was identified when a resident with a diagnosis including hyperosmolality and hypernatremia was admitted to the facility and subsequently had abnormal blood work. The provider gave new orders, including a repeat basic metabolic panel (BMP) to be drawn on a specified date. Record review showed that the physician's order for the repeat BMP was not carried out as scheduled, and there was no evidence that the test was completed on the ordered date. During an interview, the Director of Nursing Services confirmed that the BMP should have been completed as ordered.
Failure to Provide Social Services Following Discharge Notice
Penalty
Summary
The facility failed to provide medically related social services to support a resident with a history of psychotic disorder and hallucinations after issuing a 30-day discharge notice for non-payment. Following the notice, the resident exhibited disruptive and self-injurious behaviors, including being found with a plastic bag over their head, which required immediate intervention and 1:1 supervision until transfer to an acute care hospital for psychiatric evaluation. Documentation and staff interviews revealed that the Social Worker was aware of the resident's distress and the presence of the resident and family at the facility but did not successfully engage with them or provide support after the notice was issued. Further review showed no evidence that the Social Worker or facility staff provided or attempted to provide the required social services to the resident or their representative following the issuance of the 30-day notice. Staff interviews confirmed expectations that social services should have intervened, and the resident's representative reported being unaware of the Social Worker's availability and not being offered case management support, despite requesting it. The lack of social service intervention was not addressed until after surveyor inquiry.
Failure to Provide Required Two-Person Assistance During Transfer Results in Resident Fractures
Penalty
Summary
A resident with Parkinson's disease, who was cognitively intact and required the assistance of two staff members with a gait belt for transfers, sustained significant fractures to the left tibia and fibula. The resident's care plan and transfer evaluation clearly documented the need for two-person assistance during transfers. However, staff interviews and documentation revealed that the resident was routinely transferred by a single nursing assistant using a stand pivot transfer (SPT) technique, contrary to the care plan requirements. Multiple staff members, including nursing assistants and the Director of Rehabilitation, confirmed that the resident was often transferred independently and that the resident had difficulty lifting their foot during transfers, which led to twisting of the leg. The resident reported hearing a pop and falling backward during a transfer when only one staff member was present. Staff schedules confirmed that the staff involved were on duty during the relevant period, and there was no evidence provided by the facility to show that two-person assistance was consistently provided as required. The investigation determined that the resident's injuries were consistent with improper or inadequate assistance during a transfer, specifically a twisting injury that can occur when a resident is not properly supported. The facility failed to ensure that the resident received adequate supervision and assistance during transfers, as outlined in the care plan and transfer evaluation, which likely contributed to the resident's fractures.
Failure to Implement and Document Physician Wound Care Orders
Penalty
Summary
A resident with a diagnosis including basal cell carcinoma was admitted to the facility and subsequently underwent MOHS surgery to remove skin cancer. Following the procedure, a dermatologist provided specific wound care orders, including daily soaks with a white vinegar and water solution and the application of Manuka Honey to raw areas on the face and neck twice daily until healed. These orders were documented on a Continuity of Care Consultation and Referral Form. Record review revealed that from September through November, there was no evidence in the Treatment Administration Records (TAR) that the dermatologist's wound care orders were implemented. There was also no documentation indicating that the facility physician had declined or verified the dermatologist's orders. During an interview, the Administrator was unable to provide evidence that the orders were followed or that any verification or declination by the facility physician had occurred.
Failure to Provide Adequate Supervision During Ambulation Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of repeated falls, and a recent hip fracture was not provided with adequate supervision during ambulation. The resident required supervision or stand-by assistance with a rolling walker, as documented in the care plan, MDS, and physical therapy discharge summary. On the day of the incident, a nursing assistant walked ahead of the resident, leaving the resident to ambulate alone with a walker. The resident let go of the walker, fell backwards, and subsequently suffered a hip fracture after attempting to get up and being struck by a door. Staff interviews revealed that the nursing assistant believed the resident was independent with walking, contrary to the documented requirements for supervision and assistance. The Director of Rehabilitation confirmed that the resident was not independent and required staff to be within arm's length during ambulation. The Director of Nursing also stated that staff are expected to follow physical therapy recommendations and the care plan, but was unable to provide evidence that adequate supervision was provided at the time of the incident.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with significant care needs. For one resident who was re-admitted with a history of a displaced intertrochanteric fracture of the left femur, documentation showed that the resident experienced a fall resulting in a hip fracture and required hospitalization and surgery. However, review of the resident's care plan did not show any evidence that the actual fall with injury was addressed or incorporated into the care plan, and the Director of Nursing Services was unable to provide documentation of a comprehensive care plan related to this incident. For another resident with diagnoses including a left patella fracture, hip pain, and dementia, the care plan contained conflicting instructions regarding transfer methods. The plan indicated the use of a mechanical lift requiring two staff for transfers, but also referenced the use of a slide board for transfers. Further documentation confirmed the resident was dependent for all transfers, yet the care plan did not specify a single, consistent transfer device. The Director of Nursing Services acknowledged the inconsistency and was unable to provide evidence of a comprehensive, person-centered care plan that accurately reflected the resident's transfer needs.
Failure to Ensure Abuse Prevention Training for Nursing Assistant
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets to provide care that assures resident safety and maximizes well-being, as required by resident assessments and individual care plans. Specifically, a review of records and staff interviews revealed that a nursing assistant, Staff A, did not complete the required Abuse Prohibition training upon hire, as mandated by facility policy. This deficiency was identified during the investigation of an alleged staff-to-resident abuse incident involving Staff A and a resident with multiple sclerosis and rheumatoid arthritis, who was cognitively intact at the time of the incident. Further review showed that the facility's Abuse Prohibition Policy requires all employees to receive training on abuse prevention during orientation and at least annually. However, there was no documentation that Staff A had received this training upon hire or after the abuse allegation was reported. The Director of Nursing Services confirmed the absence of training records for Staff A and acknowledged that additional abuse prevention training would have been expected following the incident.
Failure to Complete Weekly Skin Assessments per Care Plan
Penalty
Summary
The facility failed to implement comprehensive, person-centered care plans for three residents by not completing weekly skin assessments as required. For one resident with a history of stroke, documentation showed that weekly skin inspections had not been completed since early May, despite a care plan directive for weekly assessments. Similarly, another resident with a stroke diagnosis had a care plan for weekly skin inspections, but records indicated that assessments were missed for several consecutive weeks. In both cases, staff interviews confirmed the absence of documentation to support that the required assessments were performed. A third resident, admitted with dementia, also had a care plan specifying weekly skin checks by a licensed nurse. However, documentation revealed that the weekly skin assessment was not completed as scheduled, and the Assistant Director of Nursing was unable to provide evidence that the assessment had occurred. These findings demonstrate that the facility did not follow through with the scheduled care plan interventions for weekly skin assessments for these residents.
Failure to Ensure Nursing Staff Competency and Annual Skills Assessment
Penalty
Summary
The facility failed to ensure that nursing staff, including both registered nurses (RNs) and licensed practical nurses (LPNs), had completed required annual competencies and skill assessments as outlined in the facility assessment. Specifically, there was no evidence that four nurses, hired between 2009 and 2023, had completed their annual nursing competencies since 2023. Additionally, the facility assessment indicated that staff must be competent in providing IV therapy, including the management and administration of medications via a peripherally inserted central catheter (PICC). However, competency records for three nurses did not show completion of the required yearly IV competency for PICC line care. During an interview, the Clinical Market Advisor was unable to provide documentation confirming that any of the identified staff had completed their annual competencies as required by the facility's own assessment. The deficiency was identified through record review and staff interviews, and it was determined that the facility did not ensure staff had the necessary competencies and skill sets to provide safe and appropriate care for the resident population, including those requiring IV therapy.
Failure to Properly Store, Label, and Dispose of Medications
Penalty
Summary
Surveyor observations and staff interviews revealed multiple failures in the facility's medication management practices. On one occasion, a medicine cup containing a Tylenol tablet was left unattended on top of a medication cart in the hallway, with the Certified Medication Technician admitting to dispensing the medication and leaving it out instead of discarding it. Additional observations of medication carts found opened Lantus insulin pens and a Breo Ellipta inhaler without dates, as well as an expired Lantus insulin pen and an opened Active Liquid Protein container without a date, all contrary to manufacturer instructions and facility policy. Staff acknowledged these items were either expired or not properly dated when opened. Further deficiencies were identified in medication rooms, where surveyors found bottles of Kayexalate and a box of Lovenox injections prescribed for residents no longer on the unit, which had not been placed in the discarded medication bin as required. Refrigerators in medication rooms contained an opened Lispro insulin pen without a date and a bottle of Lorazepam Intensol that was expired. Staff interviews confirmed awareness that these medications were either expired, not dated, or should have been discarded, but had not been managed according to policy and professional standards.
Failure to Implement Enhanced Barrier Precautions for Residents with Wounds and Catheters
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling urinary catheters. Surveyor observations revealed that residents with open wounds and a urinary catheter did not have the required EBP signage posted on their room doors, as mandated by facility policy and CDC guidance. Record reviews confirmed that these residents had physician orders for wound care and catheter management, which should have triggered EBP implementation, including the use of gowns and gloves during high-contact care activities. Interviews with nursing assistants and the unit manager indicated a lack of awareness and training regarding EBP requirements. Staff members providing direct care to affected residents were unaware that EBP and PPE use were necessary, and the unit manager acknowledged the absence of appropriate signage. The clinical market advisor also confirmed the expectation that residents with wounds or indwelling devices should be on EBP, with staff utilizing PPE during care. These findings demonstrate that the facility did not follow its own procedures or ensure staff competency in infection control practices for residents at increased risk of infection.
Failure to Provide Resident-Preferred Activities During Power Outage
Penalty
Summary
The facility failed to provide an ongoing program of activities that supported residents' choices and preferences, as identified in their comprehensive assessments and care plans, for three residents who were unable to watch television in their rooms from 5/9/2025 through 5/13/2025. All three residents had care plans and MDS assessments indicating that watching television and keeping up with the news were important or somewhat important to them. Despite this, their televisions were nonfunctional due to a power outage affecting their room outlets, and no alternative means were provided for them to engage in their preferred activities. Resident interviews revealed that each resident was dissatisfied and upset about being unable to watch television or movies, particularly over the weekend when no other activities were available. The Maintenance Director confirmed awareness of the power outage affecting the outlets, and the Clinical Market Advisor stated that it was expected that affected residents should have been offered tablets to watch television or movies, but this was not done. The lack of timely intervention resulted in the residents being left without meaningful activities aligned with their preferences for several days.
Failure to Provide Consistent Pressure Ulcer Prevention and Assessment
Penalty
Summary
A resident with a history of right femur fracture, osteoarthritis, and non-ambulatory status was identified as being at risk for skin breakdown upon admission. The resident's care plan included interventions such as providing preventative skin care as ordered and conducting weekly skin checks by a licensed nurse. However, documentation revealed that staff failed to provide preventative skin care for 32 out of 36 opportunities in May, and weekly skin assessments were not completed after the initial assessment on 5/1/2025. Interviews with staff confirmed the lack of ongoing skin assessments and preventative care as outlined in the care plan. During interviews and direct observation, the resident reported having bed sores on the buttocks, and staff observed pink, blanchable areas on both buttock cheeks. The facility's wound nurse and Assistant Director of Nursing acknowledged that residents with impaired mobility and a history of pressure injuries require preventative skin care and regular assessments, but could not provide evidence that these interventions were consistently implemented for this resident. The failure to follow the care plan and professional standards of practice led to the deficiency in pressure ulcer prevention and care.
Failure to Address Significant Weight Loss and Notify Clinical Staff
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident who experienced a significant weight loss. According to the facility's own policy, licensed nurses are required to monitor and document weights, review significant weight changes, and notify the physician and dietitian when such changes occur. The resident, admitted with diagnoses including sepsis and diabetes mellitus, was identified as being at nutritional risk and had a physician's order for weekly weights. Despite this, the resident experienced a 6.7% weight loss over a short period, with weights documented almost daily showing a consistent decline. There was no evidence in the record that any nutritional intervention was implemented in response to the weight loss. Interviews with the Registered Dietitian and the resident's physician revealed that neither was aware of the significant weight loss, and the dietitian stated she would have intervened if notified. The Assistant Director of Nursing confirmed that the facility's computer system is designed to trigger alerts for significant weight loss, which should prompt a reweigh and further assessment, but this process was not followed for the resident in question.
Failure to Document and Monitor PICC Line Care for Resident Receiving IV Antibiotics
Penalty
Summary
The facility failed to adhere to professional standards of practice for the administration and monitoring of intravenous (IV) therapy for a resident with a peripherally inserted central catheter (PICC) who was receiving IV antibiotics for enterococcal bacteremia. The resident was admitted with a PICC line in place and had physician orders for regular dressing changes, as well as for documentation of the external catheter length and upper arm circumference, with instructions to notify the practitioner if the catheter length changed. However, the hospital transfer documentation did not include the required initial measurements, and subsequent facility records did not show evidence that these measurements were ever obtained or documented. Medication Administration Records indicated that PICC line dressing changes were signed off as completed by a registered nurse on two occasions, but during interviews, the nurse admitted to signing off in error and stated she had never performed the dressing changes. Additionally, there was no documentation of the required measurements on the dates dressing changes were recorded. Observations confirmed discrepancies in the dressing change dates and staff involved. Facility leadership and clinical staff were unable to provide evidence that the necessary monitoring and documentation for the PICC line had been completed as ordered.
Failure to Monitor Dialysis Access Site per Policy and Care Plan
Penalty
Summary
A resident with end stage renal disease and dependence on renal dialysis was admitted to the facility in April 2023. The facility's policy required licensed nurses to check the dialysis access site for patency by auscultating for a bruit and palpating for a thrill before and after dialysis and every shift. The resident's care plan also included an intervention to monitor the dialysis access site for a positive bruit and thrill every shift and as needed. However, there was no evidence in the medical record of a physician's order to perform these assessments as required by the facility's policy and the resident's care plan. Additionally, documentation review showed that the last recorded assessment of the dialysis site for bruit and thrill occurred on 9/21/2024, with no subsequent assessments documented until the issue was identified by surveyors. Staff interviews confirmed the absence of an order to monitor the dialysis access site as per policy, and the order was only obtained after the surveyor brought the concern to the facility's attention. This failure resulted in the resident not receiving dialysis access site monitoring consistent with professional standards of practice and the comprehensive person-centered care plan.
Failure to Act on Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that irregularities identified by the Clinical Consultant Pharmacist during the monthly Medication Regimen Review (MRR) were reviewed and acted upon by the residents' providers for three of six residents reviewed. For one resident, the pharmacist recommended decreasing the Lantus insulin dose and evaluating the Sitagliptin dose, as it exceeded the manufacturer's maximum recommended amount. For another resident, the pharmacist recommended evaluating the continued need for lorazepam, reviewing the diagnosis and usage pattern, and either discontinuing the order or specifying the duration for the PRN order. For a third resident, the pharmacist identified duplicate PRN orders for phenazopyridine, recommended clarifying acetaminophen dosing to not exceed 3 grams daily, and suggested specifying the amount of fluid to mix with Miralax. Record review did not reveal evidence that these recommendations were reviewed or acted upon by the residents' providers. During an interview, facility leadership was unable to provide documentation that the pharmacy consultation reports were reviewed and addressed as required by facility policy and procedure.
Failure to Administer Prescribed Warfarin Doses
Penalty
Summary
A deficiency occurred when a resident receiving Warfarin therapy did not receive prescribed doses of the medication on two consecutive days. The resident, who had a history of atrial fibrillation, hypertension, and a cardiac pacemaker, was admitted with physician orders for specific Warfarin dosing and regular PT/INR monitoring. Documentation showed that the resident's PT/INR was within the therapeutic range prior to the missed doses, and the physician had ordered continuation of the Warfarin regimen with follow-up lab testing. However, review of the Medication Administration Record (MAR) revealed that the resident did not receive Warfarin on the specified dates, and there was no evidence of a Warfarin order being implemented on one of those days. Subsequently, the resident's PT/INR dropped below the therapeutic range, as confirmed by lab results. The Assistant Director of Nurses acknowledged during interview that the resident missed the Warfarin doses on the identified dates.
Improper Disposal of Garbage and Refuse in Dumpster Area
Penalty
Summary
Surveyor observation of the facility's outside dumpster area, in the presence of the Food Service Director, revealed improper disposal of garbage and refuse. Various items, including broken down cardboard boxes, used surgical and N95 masks, a tall cardboard box containing wood wall baseboard pieces, used bubble wrap, a mattress, five pieces of wood, and a large metal bed frame, were found scattered on the ground surrounding the dumpster. During an interview, the Maintenance Director acknowledged the presence of these items and confirmed that the area needed to be cleaned and the items discarded.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish and implement an effective Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program, as required. Specifically, the facility did not ensure that antibiotic use protocols were followed for two residents. According to the CDC and the facility's own policy, antibiotic stewardship should include standardized practices for evaluating residents suspected of infection, optimizing diagnostic testing, and conducting antibiotic reviews or 'time-outs' after antibiotics are initiated. The facility reported using the McGeer’s Criteria for identifying infections, which requires specific clinical and laboratory findings before starting antibiotics for residents with indwelling catheters. For one resident with a history of nontraumatic intracerebral hemorrhage and an indwelling catheter, a physician ordered Bactrim DS for a possible urinary tract infection after the catheter was changed and purulent urine was observed. Although diagnostic tests were ordered, there was no evidence that an antibiotic review or time-out was completed after the antibiotic was started, as required by the facility’s policy and CDC guidelines. This omission was acknowledged by facility leadership during the survey. For another resident with atrial fibrillation and an indwelling catheter, ceftriaxone was started for a suspected urinary tract infection following episodes of hematuria. However, there was no evidence that the resident met the McGeer’s Criteria prior to starting the antibiotic, and subsequent urine culture results showed no bacterial growth. Facility staff were unable to provide documentation that the antibiotic stewardship program was followed in this case, as required by policy.
Failure to Immediately Notify Resident's Representative After Fall and Hospital Transfer
Penalty
Summary
The facility failed to immediately notify a resident's representative following an accident that resulted in injury and required transfer to an acute care hospital. According to the facility's policy, immediate notification of the patient, physician, and representative is required in the event of an accident resulting in injury and a decision to transfer the patient. Record review showed that the resident, who had a history of stroke, sustained a fall resulting in a laceration above the left eye that required sutures. Documentation indicated that the name of the family or representative notified was listed as unknown shortly after the incident. Further review of records did not provide evidence that the resident's representative was informed immediately of the accident and subsequent hospital transfer. During an interview, the Assistant Director of Nursing Services was unable to provide proof that the required notification occurred. The lack of timely communication with the resident's representative following the incident constituted a deficiency in meeting regulatory requirements.
Failure to Complete and Document Post-Fall Neurological Assessments
Penalty
Summary
The facility failed to meet professional standards of quality by not completing required neurological assessments for two residents following falls, as identified through record review and staff interviews. For one resident with a history of stroke who sustained a fall resulting in a head laceration and required sutures, there was no evidence that the facility's neurological assessment protocol was initiated after the resident returned from the emergency room, despite provider recommendations and facility policy requiring such assessments for head injuries or unwitnessed falls. The Assistant Director of Nursing was unable to provide documentation that the neuro checks were completed as required. For another resident with dementia who experienced an unwitnessed fall, the facility's neurological evaluation flow sheet indicated that assessments were to be performed at specific intervals following the incident. However, documentation was missing for all required assessment times within the first two hours post-fall. The Assistant Director of Nursing confirmed that the neurological evaluation was not completed in its entirety and acknowledged that staff did not document the assessments as expected per facility policy.
Failure to Monitor and Document Nutritional Status
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable nutritional status, as evidenced by significant weight fluctuations that were not properly addressed. The resident, who was readmitted with serious medical conditions including brain cancer and difficulty swallowing, experienced a 9.2% weight loss upon readmission, followed by an 8.72% weight gain, and then a 6.42% weight loss. Despite these significant changes, there was no evidence that the resident was re-weighed to confirm the accuracy of these measurements, as required by the facility's policy. Interviews with staff, including a registered nurse and the dietitian, confirmed that the resident should have been re-weighed after each significant weight change. Additionally, there was incomplete documentation of the resident's meal and snack intake over a two-week period, with several days lacking any recorded intake. The dietitian was not notified of the significant weight loss, which would have prompted a nutritional intervention. Interviews with the speech therapist and nursing assistant revealed that meal intakes were supposed to be documented in the electronic record, but this was not consistently done. The Director of Nursing Services acknowledged the lack of re-weighing and incomplete meal documentation, which were contrary to the facility's policies.
Failure to Honor Resident's DNR Order
Penalty
Summary
The facility failed to honor a resident's Advanced Directive, specifically a Medical Orders for Life Sustaining Treatment (MOLST) form, which indicated a Do Not Resuscitate (DNR) order. The resident, who was readmitted to the facility with conditions including Atrial Fibrillation, acute osteomyelitis of the left hand, and diabetes, passed away within 24 hours of admission. Despite the MOLST form being signed by a Nurse Practitioner and completed with the resident's next of kin, staff initiated cardiopulmonary resuscitation (CPR) and used a defibrillator when the resident was found unresponsive. During the surveyor's interview with the Assistant Director of Nursing Services (ADNS), it was acknowledged that the resident had a DNR order, and the staff should not have performed CPR. The incident was reported to the Rhode Island Department of Health, and the ADNS confirmed the oversight in following the resident's MOLST form, which clearly stated the resident's wish to allow natural death without resuscitation efforts.
Incomplete Wound Care Orders for Resident
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for a resident with a wound care need. The resident was admitted with diagnoses including bacteremia, a methicillin susceptible staphylococcus infection, and a Stage IV pressure injury to the left ischium. A hospital document indicated that the wound required treatment with Dakins 0.125% and packing with a wet to dry dressing twice daily and as needed. However, the physician's order dated four days after admission only included the application of Sodium Hypochlorite Solution 0.125% twice daily, without instructions for wound packing or specifying the wound location. The Treatment Administration Records for June and July 2024 showed that the treatment was signed off as administered, despite the incomplete order. During an interview, the Director of Nursing Services acknowledged the deficiency, noting that the wound treatment order lacked necessary details for wound packing and the specific area for treatment application. This oversight indicates a failure to transcribe a complete and accurate order for the resident's wound care, as expected by professional standards.
Unnecessary Drug Administration Due to Transcription Error
Penalty
Summary
The facility failed to ensure a resident's drug regimen was free from unnecessary drugs, as evidenced by the administration of additional doses of an antibiotic beyond the prescribed amount. The resident, who was admitted in June 2024 with diagnoses including bacteremia, methicillin susceptible staphylococcus infection, and osteomyelitis, was ordered to receive Meropenem intravenously for 49 doses. However, the Medication Administration Record for July 2024 showed that the resident received four extra doses of Meropenem beyond the ordered 49 doses. These additional doses were administered on July 15 and July 16, 2024. During an interview, the Director of Nursing Services acknowledged the error and explained that the resident had missed two doses on July 2 and July 5, 2024. The nurse responsible for transcribing the missed doses to be added to the order entered the end date incorrectly, leading to the administration of the extra doses.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and distributed in accordance with professional standards for food service safety, as observed by surveyors in the main kitchen and three kitchenettes. During the initial tour of the kitchen, a large package of hot dogs was found opened, with no label or date, which was acknowledged by the Food Service Director (FSD). Additionally, a document on the refrigerator door in the main dining area instructed staff to label all resident food items with their name and date, yet several items, including a Styrofoam cup of milk and a bagel, were found unlabeled and undated. Staff G confirmed these items should have been discarded per facility policy. Further observations in the transitional care unit and Homestead unit kitchenettes revealed multiple expired items, including yogurt, probiotic drinks, and a jar of applesauce, as well as unlabeled containers of food. The FSD and a registered nurse acknowledged these items were expired and should have been discarded. The FSD admitted that dietary staff were responsible for maintaining the kitchenettes and that the expired and unlabeled items should have been discarded, indicating a failure to adhere to the facility's food safety policies.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to assist residents in obtaining routine dental services for two residents, identified as Resident ID #69 and Resident ID #37. Resident ID #69 was admitted in July 2020 with diagnoses including cognitive communication deficit and dysphagia. Despite a physician's order for dental consults and a progress note indicating the presence of decayed or broken teeth, there was no evidence that the resident received routine dental services since admission. Observations confirmed multiple missing teeth, and interviews with the Infection Preventionist and Director of Nursing Services revealed they could not provide evidence of dental services or resident refusals. Similarly, Resident ID #37, admitted in March 2023 with dementia and dysphagia, also did not receive routine dental services. The resident's records showed a physician's order for dental consults and a progress note highlighting decayed or broken teeth. Observations noted missing and broken teeth, and an interview with an LPN confirmed the lack of evidence for dental services. Both cases demonstrate the facility's failure to provide necessary dental care as per the residents' health needs and physician's orders.
Infection Control Deficiencies in PPE Use and Wound Care
Penalty
Summary
The facility failed to provide a safe and sanitary environment to prevent the transmission of infections, particularly in relation to Enhanced Barrier Precautions (EBP) and wound dressing changes. For Resident ID #75, a nursing assistant was observed not wearing a gown while emptying a urostomy catheter bag, despite signage indicating the requirement for gown and gloves during high-contact activities. Similarly, Resident ID #97 was assisted with bathing and toileting by a nursing assistant who did not wear a gown, contrary to the care plan's instructions for maintaining EBP. Resident ID #115, who has an indwelling Foley catheter, was also subject to improper infection control practices. A staff member was observed emptying the catheter bag without wearing a gown, as required by the EBP guidelines. The Infection Preventionist confirmed the expectation for staff to wear the appropriate PPE when caring for residents on EBP. Additionally, Resident ID #329, who has a PICC line and a wound, was cared for by staff who did not adhere to the EBP requirements, including a nurse who provided wound care without wearing a gown. Furthermore, during a wound dressing change for Resident ID #329, a nurse placed a soiled dressing on the resident's bed and applied a clean dressing with ungloved hands, failing to perform hand hygiene. This action was acknowledged by the nurse and was contrary to the expected infection control practices. The Director of Nursing Services indicated that proper hand hygiene and PPE use were expected during such procedures.
Failure to Follow Physician's Orders for Fortified Diets
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by not following physician's orders for fortified diets for two residents. Resident ID #63, who was admitted with diagnoses including unspecified protein-calorie malnutrition, dysphagia, and cognitive communication deficit, was observed not receiving the prescribed double protein portions and fortified foods during multiple meals. Despite a care plan indicating the resident was at nutritional risk and required these dietary interventions, observations on several dates confirmed the resident did not receive the ordered diet. Similarly, Resident ID #88, admitted with dementia and identified as being at nutritional risk due to weight loss, was also not provided with the fortified diet as ordered. The resident experienced a significant weight loss, and observations over several days showed the resident did not receive the fortified foods prescribed. Interviews with the Registered Dietician and the Director of Nursing Services confirmed the failure to provide the ordered diets, and no evidence was available to show compliance with the dietary orders.
Failure to Apply Hearing Aids as Ordered
Penalty
Summary
The facility failed to ensure that a resident with sensorineural hearing loss received the necessary assistive devices to maintain hearing abilities. The resident, who was readmitted to the facility in November 2022, had a care plan indicating impaired communication due to hearing loss and required assistance with hearing aids. The care plan emphasized the importance of the resident engaging in meaningful daily routines, such as listening to music and the radio. A physician's order from January 2023 instructed nursing staff to apply the resident's hearing aids every morning and remove them at bedtime. However, the Medication Administration Record for May 2024 showed that the hearing aids were applied only once during the entire month, on May 1, with 'Not Applicable' documented for the remaining days. Surveyor observations on multiple occasions in late May 2024 confirmed that the resident was not wearing hearing aids and had difficulty hearing. Interviews with the resident's family member and facility staff revealed that the hearing aids were typically applied only when the resident had visitors, contrary to the physician's order. Both the Nurse Manager and the Director of Nursing Services acknowledged the oversight, with the Director of Nursing Services expressing an expectation that staff should apply the hearing aids daily as ordered.
Failure to Provide Ankle-Foot Orthosis for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with limited range of motion, specifically in obtaining an ankle-foot orthosis (AFO) to assist with mobility. The resident, who was readmitted to the facility for a short-term rehabilitation stay, had a history of hemiplegia and hemiparesis following a stroke. The care plan included the need for an assistive device, and a physician order for an AFO was placed. However, despite the order and the resident being cast for the AFO, the device was not provided to the resident as observed by surveyors over several days. The delay in obtaining the AFO was due to a lack of follow-up by the facility's Rehabilitation Services. The orthotic company had rescheduled a visit, and the necessary physician's signature on the Detailed Prescription form was not obtained. Interviews with staff revealed a lack of clarity on the process for obtaining the physician's authorization, resulting in the resident not receiving the prescribed AFO. This oversight was acknowledged by the Director of Nursing Services, who indicated that the Rehabilitation department should have ensured the resident received the device as ordered.
Failure to Follow Bowel Protocol for Resident with Constipation
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with constipation, as identified during a survey. The resident, who was admitted with diagnoses including muscle weakness and urinary incontinence, was occasionally incontinent of bowels and dependent on staff for toileting. Despite having a care plan in place to monitor and manage gastrointestinal symptoms related to constipation, the resident reported not having a bowel movement for more than four days and having to request medications for constipation. The physician's orders included a bowel protocol with specific medications to be administered if the resident had not had a bowel movement in a specified timeframe. The record review revealed that the resident did not have a bowel movement for six days, and the facility's bowel protocol was not followed. Although Miralax was administered on one occasion, there was no evidence of further interventions or that a provider was notified of the prolonged constipation. Interviews with staff indicated a lack of communication and understanding of the bowel protocol, with assumptions that electronic systems would alert nurses. The Director of Nursing Services acknowledged the failure to initiate the bowel protocol and the lack of notification to a provider, despite the resident not having a substantial bowel movement for six days.
Failure in Dialysis Communication and Follow-Up
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received services consistent with professional standards of practice. The resident, who was admitted with end-stage renal disease and hypertension, was receiving hemodialysis three times a week at a dialysis center. A Nurse Practitioner noted the resident's elevated blood pressure and requested that nursing staff send a blood pressure log to the dialysis center for recommendations. However, the communication sheet sent to the dialysis center was left blank by the center, and there was no evidence that the facility followed up with the dialysis center or notified the physician about the lack of response. Interviews with facility staff and the dialysis center's Clinic Manager revealed that the facility did not consistently send communication sheets with the resident to the dialysis center. The Medical Director indicated that nursing should have followed up with the dialysis center and notified the physician, especially given the resident's elevated blood pressure. The Director of Nursing Services could not provide evidence of effective communication with the dialysis center or physician notification, highlighting a breakdown in the communication process necessary for managing the resident's care effectively.
Failure to Provide Required Physical Therapy Services
Penalty
Summary
The facility failed to provide specialized rehabilitation services, specifically physical therapy, as required by the comprehensive plan of care for a resident with a history of cerebral infarction, hemiplegia affecting the left dominant side, and gait and mobility abnormalities. The resident, who was admitted in January 2023, expressed a desire for more therapy to aid mobility. The Minimum Data Set (MDS) assessment indicated the resident had intact cognition but required total dependence for bed mobility and transfer. An Occupational Therapy screen conducted in March 2024 identified functional impairments and requested a physical therapy evaluation, which was not completed. Interviews with the Director of Rehabilitation Services and the Director of Nursing Services confirmed the expectation that the physical therapy evaluation should have been completed following the request. However, neither could provide evidence of its completion. Staff I, the Occupational Therapist, noted the resident's hip tightness and discomfort in the wheelchair, emphasizing the need for physical therapy to assist with positioning and seating. The lack of a completed physical therapy evaluation represents a failure to adhere to the resident's care plan, resulting in unmet rehabilitation needs.
Latest citations in Rhode Island
The facility failed to follow physician orders for post-fall care for three anticoagulated residents who experienced falls. One resident on a blood thinner with a head injury was ordered to be transferred to the ED after a telehealth evaluation, but an LPN did not send the resident, citing instructions to contact a supervisor first and inability to reach that supervisor. For two other residents on anticoagulants, providers ordered intensive neuro checks (every 15 minutes, then every 30 minutes, then hourly, then every 4 hours), but staff instead performed neuro checks only once per shift for 72 hours. The DON and Medical Director acknowledged that the transfer and monitoring orders were not implemented as written.
A resident with intact cognition and psychiatric diagnoses sustained a left eyebrow laceration when another resident with a documented history of escalating aggressive and threatening behaviors struck them with a cane during a hallway dispute. The aggressive resident had multiple prior documented incidents, including verbal threats to kill others, attacking a roommate with a cane over TV volume, throwing objects during activities, and throwing a lunch plate at staff. Despite these events, the care plan was not updated with interventions to address physical aggression toward other residents, and a psychiatric recommendation for PRN trazodone for agitation, anxiety, and insomnia was only implemented as PRN for insomnia. The failure to assess, monitor, and implement effective interventions for the aggressive resident’s behaviors led to the assault and injury and, per the report, placed this and other residents at risk of serious physical and psychosocial harm.
A resident with impulse disorder, mood and anxiety diagnoses, and a history of escalating verbal and physical aggression had multiple documented incidents of threats, object throwing, and assault with a cane. Despite a psychiatric consult recommending PRN trazodone for agitation, anxiety, and insomnia, the provider order listed insomnia only, and the care plan was not updated with specific interventions to address the resident’s physically aggressive behaviors after several documented events. Subsequently, the resident struck another resident with a cane, causing a facial laceration that required wound closure and ongoing treatment.
The facility failed to properly screen and document clearance for a NA with disqualifying criminal history information before hire, as required by its abuse, neglect, and exploitation policy. A BCI check showed disqualifying information, yet the NA was hired, completed orientation, and worked independently based only on verbal disclosure of an old drug-related charge, without written details or verification. Later, a staff member reported witnessing this NA grab a resident’s face and kiss the resident on the lips, and a community complaint alleged inappropriate interactions with the same resident, prompting involvement of local police.
A resident with anxiety disorder and PTSD was unable to attend meals and activities with peers because the facility lost the resident's clothing after it was sent to laundry. The resident was observed in a hospital gown with only a few clothing items in the room, and the record lacked an admission inventory of belongings. The DON/Administrator reported that laundry was handled by an outside vendor without a tracking system or item documentation.
A resident with dementia and severely impaired cognition was subjected to repeated non-consensual kissing on the lips by an NA, who entered the resident’s room during care, verbally expressed affection, and then kissed the resident on the mouth on at least two separate occasions witnessed by staff. One staff member delayed reporting the first incident due to fear of the NA. These actions occurred despite a facility policy defining sexual abuse as any non-consensual sexual act and requiring protections of residents’ rights and well-being.
Failure to investigate allegations of resident-to-resident sexual inappropriateness: A resident with dementia and TBI was documented as being inappropriate with another resident, and psych notes later described increased sexually inappropriate behaviors toward other residents. Staff interviews showed the resident had been observed touching others and needing frequent redirection, but the DON, ADON, and Administrator acknowledged the facility did not complete an investigation or recognize the allegation as possible abuse.
A resident with dementia and a hearing deficit did not receive ear care as ordered because the chart lacked the Debrox order and the ear was flushed before the intended Debrox course was completed. In a separate incident, staff witnessed inappropriate kissing of a resident with dementia, but the allegation was not reported to the provider and the care plan was not updated. A third resident’s wound care was also not completed as ordered when an RN used normal saline instead of the prescribed Vashe wound wash.
A resident with migraines and chronic pain did not receive timely pain management after repeatedly reporting a migraine and appearing in visible distress. An NA notified an LPN, an RN said she could not access the med cart, and the resident continued waiting while the LPN was off the unit; the PRN migraine medication was not given until 40 minutes after the first complaint. The DON acknowledged the resident should not have waited that long for pain medication.
A resident missed 6 doses of a prescribed antibiotic, and the MAR did not show that the provider was notified. The RN acknowledged the missed doses and said they should have been reported, while the Medical Director stated she was unaware of the missed doses and would have extended the antibiotic course if informed. The DON also confirmed the missed doses and expected provider notification for any missed antibiotic dose.
Failure to Follow Post-Fall Physician Orders for Anticoagulated Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement physician orders for post-fall care, including hospital transfer and neurological monitoring, for residents on anticoagulant therapy. One resident with atrial fibrillation on Xarelto experienced an unwitnessed fall with a scalp laceration and head lump. The on-call provider, after a telehealth evaluation, ordered transfer to the ED and wrote an order directing that the resident be sent to the hospital. The resident was not transferred as ordered, and an additional order for vital signs and neuro checks every shift for 72 hours after the fall was not completed as ordered on one of the shifts. The LPN caring for this resident stated she did not send the resident to the ED because she had been instructed to call a supervisor before sending residents out, and she was unable to reach the supervisor during the shift. A second resident, also with atrial fibrillation and on Xarelto, had an unwitnessed fall with injury. The on-call provider was notified and ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, then every four hours for an additional 24 hours. A physician’s order reflecting this schedule was scanned into the EMR. However, the neuro checks were not completed as ordered; instead, they were performed only once per shift for 72 hours. The RN who authored the progress note documented the fall and the resident’s anticoagulant use, and later stated she could not remember why she did not transcribe and complete the neuro checks as ordered. A third resident with atrial fibrillation on Apixaban had a non-injury fall after attempting to walk independently. The on-call provider ordered neuro checks every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, and then every four hours for an additional 24 hours, and this order was scanned into the EMR. The record did not show that these neuro checks were completed as ordered; instead, neuro checks were documented only once per shift for 72 hours. The Medical Director stated he would have expected the first resident to be transferred to the ED as ordered and that the facility should not override a provider’s order. The DON acknowledged that the transfer order and the ordered monitoring for the first resident were not followed as written, and that for the second and third residents, staff performed only once-per-shift neuro checks instead of the more frequent monitoring ordered by the providers.
Failure to Manage Escalating Aggression Leading to Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident, Resident ID #1, from abuse by another resident with a known history of escalating aggression, Resident ID #2. Resident ID #1 was admitted in October 2025 with diagnoses including paranoid schizophrenia and adjustment disorder with mixed anxiety and depressed mood, and had a BIMS score of 14/15, indicating intact cognition. On 4/27/2026, progress notes documented that Resident ID #1 was on the receiving end of a physical altercation with another resident and was found with a deep bleeding abrasion to the left eyebrow. A subsequent nursing note described a new laceration to the left eyebrow measuring 0.5 cm by 2.0 cm by 0.1 cm, related to a resident-to-resident incident, for which wound closure strips were applied. Resident ID #1 requested police involvement and a police report, and refused transfer to the hospital for sutures. Resident ID #2 had been admitted in December 2024 with multiple psychiatric and behavioral diagnoses, including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed a BIMS score of 13/15 and documented both physical and verbal behaviors during the look-back period. Progress notes over several months recorded a pattern of escalating aggressive and threatening behaviors: on 9/13/2025, Resident ID #2 threatened to slit another resident’s throat and made additional threats toward staff; on 11/7/2025, the resident was involved in a verbal dispute with raised voice, name-calling, and verbal threats; on 12/28/2025, after another resident struck Resident ID #2 with a helmet, Resident ID #2 was overheard threatening to kill that resident if touched again. On 2/21/2026, the on-call provider documented that Resident ID #2 attacked a roommate with a cane over TV volume and required ER transfer for psychiatric evaluation. Subsequent notes on 3/9/2026 and 4/10/2026 described the resident throwing poker chips on the floor, yelling and swearing at staff and residents, and throwing a lunch plate across the nurses’ station at a nursing assistant due to dissatisfaction with portion size. Despite this documented pattern, the care plan for Resident ID #2, dated 1/16/2025, only indicated a behavior problem of being verbally aggressive toward staff with resident-to-resident altercations on 12/28/2025, 2/21/2026, and 4/27/2026, and record review failed to show added interventions to mitigate the risk of physical aggression toward other residents after the 2/21/2026 cane attack and the object-throwing incidents on 3/9/2026 and 4/10/2026. A psychiatric evaluation on 4/23/2026 recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order entered on 4/24/2026 specified trazodone 25 mg twice daily as needed only for insomnia, and record review did not show that agitation and anxiety were included as indications for use. During interviews, the RNP and the DON stated it was their expectation that agitation and anxiety would have been included in the trazodone order, and the DON was unable to provide evidence that the care plan had been updated with interventions to address Resident ID #2’s physically aggressive behaviors documented on 2/21/2026, 3/9/2026, and 4/10/2026. On 4/27/2026, the DON documented that Resident ID #2 was ambulating down the hall toward his/her room while Resident ID #1 was walking in the opposite direction, and the two residents began a verbal dispute. Before staff could intervene, Resident ID #2 used his/her cane to make contact with Resident ID #1, resulting in the eyebrow laceration that required steri-strips and ongoing wound treatment. A police incident report recorded that Resident ID #1 stated being struck with a walking cane, wanted to press charges, and that Resident ID #2 admitted to striking Resident ID #1, leading to an arrest on one count of felony assault with a dangerous weapon. The facility’s failure to assess, monitor, and implement effective interventions for Resident ID #2’s known and escalating aggressive behaviors, including failure to update the care plan after prior incidents and failure to fully implement psychiatric recommendations, resulted in this resident-to-resident altercation and injury, and the report states that this failure placed Resident ID #1 and other residents at risk of serious physical and psychosocial harm.
Failure to Implement Psychiatric Recommendations and Update Behavior Care Plan Leading to Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health services and care planning for a resident with a documented history of psychiatric conditions and aggressive behaviors. The resident was admitted in December 2024 with diagnoses including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed intact cognition with a BIMS score of 13/15 and documented physical and verbal behaviors during the look-back period. Over time, multiple behavioral incidents were recorded, including threats to slit another resident’s throat during a smoking session, verbal disputes with name-calling and threats, and a statement to another resident that if touched again the resident would be killed. Further documentation showed escalating behaviors, including an incident where the resident attacked a roommate with a cane over television volume and required ER transfer for psychiatric evaluation, throwing poker chips and yelling when not winning at Bingo, causing the roommate to avoid the shared bathroom due to inappropriate comments and frustration over the light being turned on at night, and throwing a lunch plate across the nurses’ station at a nursing assistant over portion size. The care plan, initiated in January 2025 for verbal aggression and resident-to-resident altercations, did not contain added interventions to address the resident’s physically aggressive behaviors toward others after the incidents on 2/21/2026, 3/9/2026, and 4/10/2026. The DNS later could not provide evidence that the care plan had been updated with interventions to mitigate the risk of these physically aggressive behaviors or to guide staff in ensuring the safety of other residents. On 4/23/2026, a psychiatric evaluation recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order dated 4/24/2026 implemented trazodone 25 mg twice daily as needed for insomnia only, and the record lacked evidence that agitation and anxiety were included as indications for use as recommended by the consulting psychiatrist. Both the RNP and the DNS stated it was their expectation that the trazodone order would have included agitation and anxiety. Following this incomplete implementation of the psychiatric recommendation and the lack of updated behavioral interventions in the care plan, a resident-to-resident altercation occurred on 4/27/2026 in which the resident struck another resident with a cane, causing a laceration to the left eyebrow that required closure with steri-strips and ongoing wound treatment.
Failure to Properly Screen and Clear NA with Disqualifying Criminal History
Penalty
Summary
The facility failed to ensure that a prospective employee was properly screened and cleared for a history of abuse, neglect, exploitation, or misappropriation of resident property before hire. A nursing assistant, identified as Staff A, was hired on 11/18/2025 and was working independently as a NA. Prior to hire, a Bureau of Criminal Identification (BCI) check dated 11/6/2025 showed that Staff A had disqualifying information under federal and state law. Surveyor review after discovery of the positive BCI revealed that Staff A had an extensive criminal history. Despite this, the facility proceeded with the hire and allowed Staff A to complete orientation and work independently without obtaining or maintaining documentation specifying the nature of the disqualifying information, contrary to the facility’s Abuse, Neglect and Exploitation Policy, which requires screening and documentation of proof that such screening occurred. Subsequently, a facility-reported incident submitted on 4/17/2026 documented that a staff member reported witnessing Staff A grab a resident’s face and kiss the resident on the lips. A community-reported complaint submitted on 4/22/2026 alleged inappropriate interactions between the same NA and the same resident, and included a local police incident report indicating the resident’s family intended to pursue charges related to the incident. During interviews, the Human Resource Director stated that Staff A had disclosed disqualifying information related to a prior drug-related charge from about ten years earlier, but acknowledged there was no documentation specifying the nature of the disqualifying information and that this was known only by word of mouth. The Administrator stated she was aware that the BCI contained disqualifying information and that she exercised her own judgment in proceeding with the hire, and further acknowledged she did not receive documentation detailing the disqualifying information until it was brought to her attention by the surveyor.
Failure to Maintain Resident Clothing and Dignity
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity when the resident was unable to attend meals and activities with other residents because of a lack of appropriate clothing. The resident was admitted in May 2025 with diagnoses including anxiety disorder and post-traumatic stress disorder, and a care plan revised on 8/25/2025 described the resident as highly social and willing to participate in a variety of activities, with an intervention to provide reminders of scheduled events. During observation on 4/29/2026, the resident was found in the room wearing a hospital gown while other residents were in the dining room for lunch. Only one pair of pants and two T-shirts were observed in the room. The resident stated that the facility lost all of the resident's clothing, including shirts, pants, shorts, and socks, after they were sent to laundry services several months earlier and were never returned. The resident reported that the Administrator was told about the missing clothing, but no follow-up occurred and the clothing was neither located nor replaced. The record did not contain an admission inventory list of the resident's belongings, and the Administrator stated that laundry was handled by an outsourced company without a tracking system or documentation identifying which items belonged to which resident.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse when a nursing assistant (NA) was observed kissing the resident on the lips on more than one occasion. The resident, identified as having dementia and a Brief Interview for Mental Status (BIMS) score of 0/15 indicating severely impaired cognition, had been admitted in March 2026. On one occasion, a Certified Medication Technician (CMT) reported that while she was assisting the resident with breakfast, the NA entered the room, verbally expressed affection for the resident, made a kissing noise, leaned forward, and kissed the resident on the lips. This incident made the CMT uncomfortable, and she later discussed it with another NA. A separate staff member, another NA, reported that two days earlier she had observed the same NA enter the resident’s room while morning care was being provided, ask the resident if they remembered her, state that she loved the resident, then lean toward the resident, make a kissing sound, and kiss the resident on the mouth with full lip-to-lip contact. This second NA did not report the incident at the time because she was fearful of the NA involved and only came forward after learning of the later incident. The facility’s abuse, neglect, and exploitation policy defined sexual abuse as a non-consensual sexual act of any type with a resident and required protections for each resident’s health, welfare, and rights, as well as screening of potential employees for a history of abuse. Despite this policy, the resident with severely impaired cognition was subjected to repeated non-consensual kissing by the NA.
Failure to Investigate Allegations of Resident-to-Resident Sexual Inappropriateness
Penalty
Summary
The facility failed to ensure that allegations made by residents were recognized as possible abuse by staff and that all allegations were investigated for Resident ID #41, who was admitted with diagnoses including dementia and traumatic brain injury. A facility policy titled, Abuse, Neglect and Exploitation, stated that an immediate investigation is warranted when suspicion of abuse, neglect, exploitation, or reports of abuse, neglect, or exploitation occur. A progress note written by an RN documented that a resident reported Resident ID #41 was being inappropriate with another resident. Subsequent records included psychiatric evaluations stating the resident was being seen due to increased sexually inappropriate behaviors toward other residents and that sexual impulses may present an unsafe environment for other patients in the facility. Staff interviews revealed that Resident ID #41 had been observed touching other residents' shoulders and hands and required frequent redirection. The RN who documented the incident stated the behavior involved an attempted hug without contact and that both residents were separated and assessed, while the ADON and DON acknowledged they were unaware of the behavior or that the facility had not investigated the allegations. The Administrator also acknowledged that an investigation had not been completed to determine what sexually inappropriate behavior had occurred and that staff did not identify the allegation as possible abuse or investigate it immediately.
Failure to Follow Orders, Report Abuse, and Perform Ordered Wound Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for a resident with dementia and anxiety disorder who had a hearing deficit and complained of right ear wax buildup. The medical record showed an order for Debrox ear drops and a separate order to flush the right ear with warm water two times a day following Debrox usage for 5 days, but the record did not include a physician order for the Debrox solution. The April 2026 MAR showed the resident’s right ear was flushed six times, and the resident stated that the right ear still felt blocked. The RN acknowledged flushing the ear and was unaware whether Debrox had been given, while the DON stated the order had been entered incorrectly and that the ear should not have been flushed before Debrox administration. The NP stated the intended order was for Debrox twice daily for five days before irrigation and that she would not have ordered daily ear flushing. The facility also failed to report an allegation of abuse and failed to update the care plan for a resident with dementia after staff reported inappropriate interactions with a nursing assistant. A community complaint and police incident report indicated the family wanted to press charges, and the Administrator and DON confirmed that staff had reported witnessing the nursing assistant kiss the resident on two occasions. The record did not show that the allegation was reported to the provider, and the comprehensive care plan was not updated to reflect the allegation or any interventions related to the incident. The NP stated she was unaware of the incident and would have expected to be notified, and the ADNS acknowledged that the provider had not been notified and the care plan had not been updated. The facility further failed to follow a wound care order for a resident readmitted with peripheral vascular disease and cellulitis of the lower limb. The physician ordered cleansing open areas on the left lower leg with Vashe wound wash, applying xeroform to the wound bed, and wrapping with kling. During observation, the RN performing wound care did not use Vashe wash and instead cleansed the wound with normal saline. The RN acknowledged using normal saline rather than the ordered cleanser, and the DON stated she would expect the nurse to follow the wound orders as written.
Delayed Pain Medication for Resident with Migraine
Penalty
Summary
Safe, appropriate pain management was not provided for Resident ID #17, who was admitted with diagnoses including migraines and chronic pain. The resident’s care plan dated 4/20/2026 included a goal for the resident to verbalize adequate pain relief and an intervention to respond immediately to any complaint of pain. The physician ordered Butalbital-APAP-Caffeine 50-300-40 mg, 1 capsule every 12 hours as needed for migraine pain. On 4/29/2026 at 10:30 AM, the resident was observed in the hallway complaining of a migraine, moaning in pain, and holding his/her head. At 10:34 AM, an NA reported to an LPN that the resident wanted pain medication, and at 10:37 AM the resident continued to complain of migraine pain and told an RN about the pain, but the RN stated she did not have keys to the medication cart and could not get any pain medication. The resident continued to complain of severe head pain, returned to the room to lie down at 10:40 AM, and the LPN was still off the unit at 10:42 AM. The resident was not assessed when the LPN returned, and the medication was not administered until 11:10 AM, 40 minutes after the initial complaint. The resident later reported pain rated 7 out of 10, and the DON acknowledged that a resident should not wait 40 minutes for pain medication.
Missed Antibiotic Doses Not Reported to Provider
Penalty
Summary
The facility failed to ensure that Resident ID #17 was free from significant medication errors when the resident missed 6 doses of a prescribed antibiotic. The resident was admitted in April 2026 with diagnoses including surgical aftercare and complication of surgical and medical care, and had a physician order dated 4/3/2026 for Cefadroxil 500 mg by mouth twice daily for 14 days. Review of the April 2026 MAR showed missed doses on 4/3 at 8:00 PM, 4/6 at 8:00 PM, 4/11 at 8:00 PM, 4/12 at 8:00 AM, 4/14 at 8:00 PM, and 4/17 at 8:00 AM. The record did not show that the provider was notified of the missed antibiotic doses. During interview, the RN acknowledged the 6 missed doses and stated they should have been reported to the provider. The Medical Director stated she was unaware of the missed doses and said she would have extended the antibiotic course if she had known. The DON also acknowledged the missed doses and stated she would expect the provider to be informed if a resident misses any dose of an antibiotic.
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