Sunny View Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Warwick, Rhode Island.
- Location
- 83 Corona Street, Warwick, Rhode Island 02886
- CMS Provider Number
- 415023
- Inspections on file
- 22
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 1 (1 serious)
Citation history
Health deficiencies cited at Sunny View Nursing Home during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia and severe BIMS impairment, care planned and ordered to wear a wander guard with regular placement and function checks, eloped from the facility after being last seen in an activity room with a visitor. Staff later could not locate the resident for dinner, and searches were initiated while the resident’s whereabouts were unknown for several hours. Witnesses, including the Activities Director, Receptionist, another resident’s family member, and the visitor, reported that the resident and visitor exited through the main entrance without a wander guard alarm sounding and without use of a door code. The visitor admitted driving the resident to the spouse’s home without notifying staff. EMS and hospital records documented that the resident had been missing for several hours, was confused, could not recall events, and reported severe throat and chest pain, arriving at the hospital with an ankle monitoring device in place. Upon the resident’s return, the facility discarded the original wander guard without testing its functionality and could not provide evidence of consistent monitoring per policy and physician orders, resulting in an Immediate Jeopardy situation.
A resident with severe cognitive impairment and a history of wandering was not consistently provided with a required TekTone elopement prevention device, as facility policy and physician orders were not followed. The device was not checked every shift, and documentation was lacking. As a result, the resident was able to exit the facility undetected, was found outside without the device, and sustained a significant injury.
A resident with severe cognitive impairment and a known risk for wandering was not properly monitored due to an incorrectly transcribed physician order for checking a TekTone elopement prevention device. The device was not checked every shift as required, and documentation was incomplete, resulting in the resident eloping from the facility without the device and sustaining a hip fracture.
A resident with mild cognitive impairment and a history of elopement risk was not accurately coded in the MDS for use of a TekTONE elopement prevention bracelet, despite care plan documentation and staff acknowledgment of the device's use. The MDS Coordinator confirmed the omission, and the DNS could not provide evidence of proper documentation in the assessment.
Two residents with complex medical conditions did not have required weekly skin assessments documented, despite physician orders and MAR sign-offs indicating completion. The DON was unable to provide evidence that these assessments were performed or recorded as required.
A resident's medical records were not accurately maintained, leading to incorrect documentation of Spironolactone administration and unfulfilled orders for hemorrhoid treatment and blood pressure monitoring. The facility failed to transcribe and implement new medical orders, and the administrator could not provide evidence of accurate documentation until prompted by a surveyor.
The facility failed to meet food safety standards, with several items in the kitchen and dining room found open and undated, contrary to the Rhode Island Food Code. Additionally, ground beef was stored without proper labeling, and steamed broccoli was served at an unsafe temperature. The Food Service Director and Dietary Cook acknowledged these lapses.
The facility failed to implement and track its QAPI actions, as shown by the absence of documented actions, measurements, or tracking systems in their 2024 and 2025 QAPI binders. Despite the QAPI plan's commitment to a formal methodology for improving performance and outcomes, no evidence of such efforts was found. The Administrator acknowledged this failure during an interview.
The facility did not complete annual performance reviews for four nurse aides, as required. A review of personnel files showed no evidence of evaluations for these staff members, and the Administrator could not provide documentation during an interview.
The facility failed to maintain an effective training program for staff, as 8 out of 10 employees reviewed did not receive required annual training in abuse, dementia management, and infection control. The Administrator could not provide evidence of completed training for these staff members.
A facility failed to provide a resident or their representative with written information about the bed-hold payment policy upon the resident's transfer to a hospital. The resident, diagnosed with congestive heart failure, was transferred without the required Bed Hold Notice being completed or documented. The Administrator acknowledged this oversight during an interview.
A resident with a history of pelvic fracture and osteoarthritis was not assisted with shaving, resulting in unwanted facial hair. Despite requiring supervision for personal hygiene, the resident was observed with facial hair, and staff interviews confirmed the lack of assistance. The DON acknowledged the oversight in care.
A resident was not administered a prescribed bowel protocol, leading to hospitalization. Despite having a physician's order for a specific bowel protocol, the resident went several days without a bowel movement, and the facility's records showed no evidence of the protocol being followed. Staff interviews confirmed the failure to implement the orders.
A resident with a stage 3 pressure ulcer did not receive the recommended foam silicone dressing treatment for 7 days after a wound specialist's assessment. The treatment was supposed to be applied three times weekly, but the facility failed to implement it, as acknowledged by the DON.
A resident with type 2 diabetes did not receive their prescribed Victoza injections on two consecutive days due to the medication being unavailable. The facility failed to order the medication promptly, leading to elevated blood sugar levels and additional insulin administration. Staff interviews revealed that the provider was not notified of the medication's unavailability, and the Director of Nursing acknowledged the oversight.
The facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) of Non-coverage Form to four residents discharged with Medicare Part A services. This form is required to inform beneficiaries about potential non-coverage and financial responsibility. The Administrator acknowledged the oversight but could not provide evidence of completed forms.
The facility failed to provide scheduled weekly showers to four residents, who were unable to perform activities of daily living independently. Despite being scheduled for showers, residents expressed frustration and reported missed showers, with no documentation to confirm when showers were provided. Staff interviews revealed that showers were given once a week without documentation, and the facility's DNS acknowledged the lack of evidence for scheduled showers.
A resident experienced an acute change in condition, including vomiting and an unknown cardiac event, but did not receive timely and thorough assessments. The DNS on the evening shift did not document vital signs or report the vomiting to the physician. Similarly, the overnight nurse did not complete a full assessment or notify the physician. The NP confirmed that vomiting should prompt assessment and notification. The lack of prompt intervention led to the resident becoming unresponsive and passing away after unsuccessful resuscitation efforts.
During a survey, tartar sauce was found stored at 62 degrees F in the dining room and 50 degrees F in the main kitchen, both exceeding the acceptable cold holding temperature of 41 degrees F. The Food Service Director confirmed the temperature deviations.
The facility failed to maintain an infection prevention and control program during a potential GI virus outbreak and did not follow proper infection control practices during a wound dressing change. Residents exhibited symptoms of a GI illness, but the facility did not initiate a line list for surveillance. Additionally, an LPN did not follow proper procedures during a wound dressing change, including not changing gloves and performing hand hygiene.
The facility failed to ensure that a resident received care consistent with professional standards of practice to prevent pressure ulcers. Despite a physician's order and care plan to offload heels while bed resting, surveyor observations revealed the resident's heels were resting directly on the mattress. This led to the development of a right heel pressure ulcer, which was confirmed by staff interviews and record reviews.
A facility failed to ensure a working call system was accessible to a resident with an upper extremity impairment. The resident's adaptive call pad was repeatedly observed out of reach, and staff confirmed it should be placed near the resident's hands due to contractures. The DON confirmed the expectation for the call pad to be within reach.
The facility failed to complete significant change in status assessments within 14 days for four residents who were admitted to hospice services, as required by CMS regulations. The Director of Nursing Services confirmed the lapse during an interview.
Elopement of Cognitively Impaired Resident Despite Wander Guard Device
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary supervision and maintain an effective elopement prevention system for a cognitively impaired resident identified as an elopement risk. The resident had diagnoses including dementia, cognitive communication deficit, and anxiety disorder, and a Quarterly MDS showed a BIMS score of 4/15, indicating severe cognitive impairment. The resident’s care plan, initiated after prior attempts to leave the facility, required use of a wander guard bracelet, weekly assessment of the device’s functioning and battery status, and visual checks or supervision for safety. Physician orders directed staff to check placement of the Tektone wander guard bracelet every shift and to check its functionality weekly. Documentation on the March Treatment Administration Record indicated the device was in place on the day of the incident and that its functionality had been checked and found operational several days earlier. On the day of the elopement, staff observed the resident wearing the wander guard bracelet in the activities room during a bingo activity in the mid-afternoon. An LPN reported last seeing the resident in the activity room seated with a visitor and wearing the wander guard. Later, when the LPN attempted to escort the resident to dinner, the resident could not be located, and a subsequent call to the resident’s spouse confirmed that the spouse did not have the resident and was unaware the resident was missing. The facility’s elopement protocol was then initiated, and staff, along with law enforcement, conducted searches of the building and surrounding community. During this time, staff and management did not know the resident’s whereabouts for several hours. Interviews and witness accounts established that the resident exited the facility through the main entrance with a visitor. The Activities Director stated that she did not see the resident or visitor leave and did not hear a wander guard alarm at the exit. The Receptionist reported seeing the resident and a visitor walking toward the main entrance and also did not hear an alarm. A visitor later admitted that she removed the resident from the facility at the resident’s request to go home, drove the resident to the spouse’s house, dropped the resident off, and left without notifying staff; she stated that the wander guard alarm did not sound when they exited and that she had never been given a door code. A family member of another resident reported seeing the visitor leave with the resident through the main entrance without hearing an alarm or seeing a code entered. The resident ultimately arrived at the spouse’s home with a sandwich in hand, appeared confused, and could not explain how they had gotten there. EMS and hospital records documented that the resident had been missing from the facility for several hours, could not recall their whereabouts, and reported severe throat and chest pain; the hospital record also noted that the resident arrived with an ankle monitoring device in place. Following the resident’s return, the facility did not evaluate or test the wander guard device that had been in use at the time of the elopement. A Regional Nurse documented that a new wander guard device was applied to the resident’s left ankle, and later acknowledged in interview that the original device had been discarded without assessment. The Regional Administrator and Regional Nurse were unable to provide evidence that the previous device had been checked or tested for functionality upon the resident’s return. The Administrator stated that it was unclear whether the wander guard system had failed, whether an alarm had sounded without staff response, or whether a visitor had entered a door code, and confirmed that visitors should not have the door code. The facility was also unable to provide documentation confirming that staff consistently monitored the resident in accordance with facility policy and physician orders. These failures resulted in the resident leaving the facility unsupervised for approximately six hours while staff were unaware of the resident’s whereabouts, placing the resident at risk for serious injury, serious harm, serious impairment, or death, and constituted a situation of Immediate Jeopardy.
Failure to Ensure Elopement Prevention Device Placement and Monitoring
Penalty
Summary
A deficiency occurred when a cognitively impaired resident, identified as being at risk for wandering and elopement, was not provided with the required elopement prevention device (TekTone bracelet) as per facility policy and physician orders. The resident had a history of dementia, cognitive decline, and other medical conditions, and was care planned for frequent visual checks and interventions to prevent elopement. The facility's policy required that the TekTone device be checked every shift, and the physician's order specified the same; however, the order was incorrectly transcribed to require checks only once weekly, and documentation showed the device was last checked three days prior to the incident. On the night of the incident, the resident was not in their room during medication administration, and staff had not seen the resident for over an hour before the resident was found outside the facility. The resident was discovered in the rear parking lot without the TekTone device, having sustained a large hematoma and a left hip fracture. Staff interviews confirmed that the resident did not have the device on at the time of the incident, and that checks for the device were not performed as required by policy or physician order. Further review revealed that the resident had previously removed the TekTone bracelet, and there was no evidence in the records that the device was consistently in place or checked as required. The facility was unable to provide documentation that the required checks were performed, and the resident's elopement was facilitated by the absence of the device, which would have triggered door locks to prevent exit. The failure to follow policy and physician orders directly led to the resident's successful elopement and subsequent injury.
Failure to Accurately Monitor and Document Elopement Prevention Device
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's medical records were complete and accurately documented regarding the monitoring of an elopement prevention device, specifically a TekTone device. The facility's policy required that the bracelet be checked each shift and documented in the treatment record. However, a physician's order to check the device every shift was incorrectly transcribed to be completed only once weekly, and documentation showed that the last check occurred three days prior to the resident's elopement. There was no evidence that the device was checked as ordered, and the resident was found outside the facility without the device, having sustained injuries including a large hematoma and a hip fracture. The resident involved had a history of dementia, cognitive decline, and severe cognitive impairment, and was identified as being at risk for wandering and elopement. The care plan included interventions such as frequent visual checks and redirecting the resident away from exits. Despite these interventions, the failure to accurately transcribe and implement the physician's order for device monitoring led to the resident's unsupervised exit from the facility and subsequent injury. Staff interviews confirmed the device was not on the resident at the time of the incident, and the order transcription error was acknowledged by the Director of Nursing Services.
Inaccurate MDS Coding for Elopement Prevention Device
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Assessment accurately reflected the status of a resident assessed as an elopement risk. Record review showed that the resident, who had diagnoses including mild cognitive impairment and muscle weakness, was readmitted to a semi-secure unit and had a care plan in place requiring the use of a TekTONE elopement prevention bracelet. Despite this, quarterly MDS assessments did not indicate the presence of the TekTONE bracelet in the Restraints and Alarms section. During interviews, the MDS Coordinator acknowledged the resident wore the bracelet and admitted it was not accurately coded in the MDS, and the DNS was unable to provide evidence that the device was documented in the assessment.
Failure to Document and Complete Physician-Ordered Skin Assessments
Penalty
Summary
The facility failed to meet professional standards of quality by not ensuring that weekly skin assessments ordered by physicians were completed and documented for two residents. For one resident admitted with altered mental status and a history of falls, a physician's order required weekly skin evaluations with documentation under observations. Although the Medication Administration Record (MAR) indicated that the assessment was completed, there was no evidence in the weekly skin evaluation observations or progress notes to confirm that the assessment was actually performed on the specified date. Similarly, another resident admitted with Parkinson's Disease, dementia, and a nasal bone fracture had a physician's order for weekly skin evaluations. The MAR showed that these assessments were signed off as completed on two occasions, but a review of the weekly skin evaluation observations and progress notes did not provide evidence that the assessments were conducted or documented as required. During an interview, the Director of Nursing Services was unable to provide documentation to support that the assessments had been completed per the physician's orders.
Failure to Maintain Accurate Medical Records and Implement Orders
Penalty
Summary
The facility failed to accurately maintain the medical record of a resident, leading to discrepancies in medication administration and unfulfilled medical orders. The resident, admitted in January 2025 with conditions such as exocrine pancreatic insufficiency, orthostatic hypotension, and repeated falls, had a medication order for Spironolactone increased from 25 mg to 37.5 mg. However, both dosages were documented as administered on the same day, despite the LPN denying the administration of the 25 mg dose. The facility administrator acknowledged the expectation for staff to discontinue the old medication order and initiate a new one, but could not provide evidence of accurate documentation. Additionally, the facility failed to transcribe and implement new orders for the resident, including the use of tucks pads for hemorrhoid pain and twice-daily blood pressure assessments. The resident reported not receiving treatment for hemorrhoid pain, and staff interviews confirmed that these orders were not transcribed or completed. The administrator was unable to provide evidence that these orders were entered into the resident's record until the surveyor brought it to their attention.
Food Safety and Labeling Deficiencies in Kitchen and Dining Room
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. In the main kitchen, several items in the reach-in refrigerator were found open and undated, including a container of fruit salad, a pitcher of orange liquid, and a bottle of prune juice. Similarly, in the main dining room kitchenette, items such as a container of whole milk, a bottle of prune juice, and a squeeze bottle of grape jelly were also open and undated. The Food Service Director (FSD) acknowledged that these items should have been labeled and dated upon opening, as per the Rhode Island Food Code. Additionally, during an inspection of the walk-in refrigerator, three white plastic tubes containing ground beef were found without labels identifying the contents. The FSD confirmed that these should have been labeled with the common name of the food. Furthermore, during the lunch meal service, the temperature of steamed broccoli with butter was recorded at 102°F, below the required safe hot holding temperature of 135°F. The Dietary Cook, Staff J, admitted to not checking the temperature before plating the meal, and the FSD confirmed that the broccoli was not at the safe temperature, indicating a lapse in food safety protocols.
Failure to Implement and Track QAPI Actions
Penalty
Summary
The facility failed to effectively implement and track its Quality Assurance and Performance Improvement (QAPI) actions, as evidenced by a lack of documented actions, measurements, or tracking systems in their 2024 and 2025 QAPI binders. This deficiency was identified during a record review and staff interview, where it was noted that the facility's QAPI plan included a commitment to using a formal and consistent methodology for planning, designing, measuring, assessing, and improving organizational performance and resident outcomes. However, the absence of evidence in the QAPI binders indicated that the facility did not follow through on these commitments. During an interview, the Administrator acknowledged the facility's failure to develop and implement systems to measure and track performance in identified problem areas.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete an annual performance review for every nurse aide at least once every 12 months, as required. This deficiency was identified during a record review and staff interview, which revealed that the personnel files for four nurse aides, Staff E, F, G, and H, lacked evidence of a completed performance evaluation within the last 12 months. Staff E was hired on 5/30/2023, Staff F on 9/27/2021, Staff G on 7/19/2021, and Staff H on 4/16/2023. During an interview with the Administrator on 3/12/2025, she was unable to provide documentation of the required evaluations for these staff members.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for annual training for existing employees, as required by their facility assessment. This deficiency was identified through a record review and staff interviews, which revealed that 8 out of 10 employees reviewed did not receive the necessary annual education or training in areas such as abuse and neglect, dementia management, and infection control. The facility assessment, dated January 1, 2024, specified that these training topics should be completed upon hire and annually for all staff. Specific staff members, including Nursing Assistants, a Dietary Cook, a Licensed Practical Nurse, and a Registered Nurse, were found to lack evidence of having received the required training. During an interview, the Administrator acknowledged the expectation that all outlined training should have been completed but was unable to provide evidence that the necessary education and training had been completed for the staff members in question.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide written information to a resident or their representative regarding the facility's bed-hold payment policy upon the resident's transfer to a hospital. This deficiency was identified for one of the two residents reviewed, specifically for a resident with a diagnosis of congestive heart failure. The facility's policy requires that a Bed Hold Notice be completed and attached to the resident's transfer papers, and that the representative's decision concerning the bed hold be documented in the resident's medical record. Upon review, it was found that the resident was transferred to the hospital, but there was no evidence that the bed hold policy was offered or documented as required. During an interview, the facility's Administrator acknowledged that the bed hold notification was not completed. This oversight indicates a failure to adhere to the facility's established procedures for notifying residents or their representatives about bed hold policies during hospital transfers.
Failure to Assist Resident with Personal Hygiene
Penalty
Summary
The facility failed to ensure that a resident maintained the ability to perform activities of daily living, specifically personal hygiene related to shaving. The resident, admitted in January 2025 with diagnoses including pelvic fracture and osteoarthritis, required supervision or assistance for personal hygiene as per the Admission Minimum Data Set (MDS) assessment. However, observations on two separate occasions revealed that the resident had a moderate amount of facial hair, approximately half an inch in length, indicating a lack of assistance with shaving. Interviews conducted by the surveyor revealed that the resident had lost their razor and had not been assisted with shaving by the facility staff, despite expressing a desire to have their facial hair shaven. Nursing Assistant, Staff A, acknowledged that she should have assisted the resident with shaving, and Registered Nurse, Staff B, confirmed that shaving is part of resident care. The Director of Nursing Services also acknowledged that the resident should have been assisted with shaving, highlighting a lapse in the facility's provision of necessary personal hygiene assistance.
Failure to Administer Bowel Protocol as Ordered
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 a bowel protocol. The resident, who was readmitted to the facility following a hospital stay for fecal impaction and a urinary tract infection, had a physician's order for a bowel protocol that included administering prune juice, Milk of Magnesia, Dulcolax suppository, and Fleet Enema in a specific sequence if bowel movements did not occur. However, documentation revealed that the resident went several days without a bowel movement on multiple occasions, and there was no evidence that the bowel protocol medications were administered as ordered from late September to mid-October 2024. The deficiency was confirmed through record reviews and staff interviews. The Medication Administration Records for September and October 2024 did not show that the bowel protocol was followed, and the resident was eventually transferred to the hospital on October 15, 2024. During interviews, both a registered nurse and the Director of Nursing Services acknowledged that the bowel protocol orders were not implemented according to the physician's instructions. This lack of adherence to the prescribed bowel protocol contributed to the resident's hospitalization.
Failure to Implement Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure that a resident with a pressure ulcer received the necessary treatment and services to promote healing, consistent with professional standards of practice. The resident, admitted in January 2025, had a diagnosis that included a pressure ulcer with an unspecified stage. A wound specialist assessment later identified a stage 3 pressure wound on the resident's right ischium. A treatment recommendation was made on March 4, 2025, to apply a foam silicone dressing three times weekly. However, the March 2025 Treatment Administration Record showed no evidence that this treatment was implemented from March 4 to March 11, 2025, resulting in a 7-day delay in treatment. The Director of Nursing Services acknowledged during an interview that the treatment was not implemented until 7 days after the wound specialist's recommendation.
Failure to Administer Victoza Leads to Medication Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Victoza, an injectable medication prescribed to help lower blood sugars. The resident, who was admitted with a diagnosis of type 2 diabetes mellitus, did not receive the Victoza injection as ordered on two consecutive days. The medication was noted as unavailable, and it was not ordered from the pharmacy until two days after the missed doses. This oversight led to elevated blood sugar levels, requiring additional insulin administration according to the sliding scale. The nursing progress notes did not indicate that the provider was notified about the unavailability of Victoza, and interviews with staff confirmed that the provider was not informed. The Director of Nursing Services acknowledged the failure to administer the medication as ordered. The lack of timely communication and action to ensure the availability of the medication contributed to the deficiency, impacting the resident's blood sugar management.
Failure to Provide SNFABN Forms to Residents
Penalty
Summary
The facility failed to provide proper notice to residents and/or their representatives regarding changes in Medicare Part A coverage, specifically related to the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) of Non-coverage Form. This deficiency was identified for four residents who were discharged with Medicare Part A services. The SNFABN is required by Medicare to inform beneficiaries when care that is usually covered may not be paid for due to reasons such as not being medically reasonable and necessary or being considered custodial. The absence of this form means that residents were not informed about their potential financial responsibility for services not covered by Medicare. Record reviews revealed that the last covered days of Medicare Part A services for the residents in question were on various dates, yet there was no evidence that the SNFABN form was issued to them or their representatives. During an interview, the facility's Administrator acknowledged that the forms should have been issued but could not provide evidence that they were completed. This oversight affected four residents, identified as Resident ID #294, #295, #296, and #297, indicating a systemic issue in the facility's process for notifying residents about changes in their Medicare coverage.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to provide necessary services to residents who were unable to perform activities of daily living, specifically regarding scheduled showers. Four residents were affected by this deficiency, as they did not receive their scheduled weekly showers. Resident ID #1, admitted with multiple rib fractures, was scheduled for a shower every Friday evening but only received 2 out of 5 scheduled showers. The resident expressed frustration and noted the lack of documentation for missed showers. Staff interviews confirmed the absence of documentation requirements for showers. Resident ID #3, diagnosed with retinitis pigmentosa, was overheard complaining about not receiving a shower for several days. The resident was scheduled for a shower every Tuesday morning, but there was no documentation to confirm when the last shower was provided. Staff interviews revealed that showers were given once a week without documentation, and a shower was only offered after the issue was brought to the facility's attention by the surveyor. Resident ID #4, with a diagnosis of depression, was dependent on staff for ADLs and had not received a shower in the past month, despite being scheduled for a weekly shower every Friday morning. Resident ID #5, with a history of falling, expressed a desire for more frequent showers than the once-a-week schedule allowed. The facility's Director of Nursing Services acknowledged the lack of documentation and the expectation for staff to accommodate residents who missed scheduled showers or requested additional ones, but no evidence was provided to confirm that the residents received their showers as scheduled.
Failure to Address Acute Change in Condition
Penalty
Summary
The facility failed to provide appropriate treatment and care for Resident ID #38, who experienced an acute change in condition involving vomiting and an unknown cardiac event. Despite the resident exhibiting symptoms such as vomiting, being pale and tired, and ultimately becoming unresponsive, there was a lack of timely and thorough assessments conducted by the nursing staff. The Director of Nursing Services (DNS) on duty during the evening shift did not document vital signs or report the vomiting to the physician. Similarly, the nurse on the overnight shift failed to complete a full assessment, including vital signs, and did not notify the physician of the resident's condition. The Nurse Practitioner (NP) acknowledged that vomiting should be considered a change in condition warranting assessment and notification to medical staff. The facility's failure to promptly identify and intervene during this resident's acute change in condition, as outlined in their policy, had serious consequences, leading to the resident being found unresponsive and ultimately passing away after resuscitation efforts were unsuccessful.
Improper Cold Holding Temperatures for Tartar Sauce
Penalty
Summary
The facility failed to properly store and serve food under sanitary conditions, as identified during a survey on 3/22/2024. Tartar sauce was observed at 62 degrees F in the dining room, above the acceptable cold holding temperature of 41 degrees F. Additionally, the tartar sauce served from the main kitchen was recorded at 50 degrees F, still not meeting the required temperature. The Food Service Director acknowledged the deviation from the acceptable cold holding temperature during an interview.
Infection Control Deficiencies in GI Illness Outbreak and Wound Dressing Changes
Penalty
Summary
The facility failed to maintain an infection prevention and control program to prevent the transmission of communicable diseases and infections during a potential gastrointestinal (GI) virus outbreak on two nursing units. Residents exhibited signs and symptoms of a GI illness, including vomiting and nausea, but the facility did not initiate a line list for appropriate surveillance as per their policy. The Infection Preventionist and Director of Nursing Services acknowledged that the outbreak protocol was not followed, and a line list was not completed for residents showing symptoms between February 8 and February 15, 2024. Additionally, the facility staff did not conduct appropriate infection control practices during wound dressing changes. A Licensed Practical Nurse (LPN) was observed changing a resident's wound dressing without removing dirty gloves, performing hand hygiene, or donning new gloves before applying the clean dressing. The LPN also touched the resident's wound care supply bag with dirty gloves and returned it to a clean supply closet, further breaching infection control protocols. The Director of Nursing Services confirmed that the nurse did not follow proper infection control practices during the wound dressing change. The facility was unable to provide evidence that it maintained an effective infection prevention and control program to prevent the transmission of communicable diseases and infections in both the GI illness outbreak and the wound dressing change scenarios.
Failure to Prevent Pressure Ulcers
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards of practice to prevent pressure ulcers. Resident ID #36, who was admitted in January 2024 with a diagnosis including traumatic hemorrhage of the cerebrum, had a physician's order to offload heels while bed resting. The care plan developed on 1/24/2024 also included approaches to prevent skin breakdown, such as keeping bony prominences from direct contact and offloading heels to reduce pressure. However, surveyor observations on multiple occasions revealed that the resident's heels were resting directly on the mattress, not offloaded as required by the care plan and physician's order. Further record review showed that there was no evidence of skin impairment to the resident's right heel on 3/5/2024 and 3/12/2024. However, a document dated 3/19/2024 revealed the development of a right heel pressure ulcer. During interviews, both a Registered Nurse and the Director of Nursing Services acknowledged that the resident's heels were not offloaded and confirmed that physician orders were not followed. The facility was unable to provide evidence that care consistent with professional standards of practice was provided to prevent pressure ulcers.
Failure to Ensure Accessible Call System for Resident
Penalty
Summary
The facility failed to ensure that a working call system was available and accessible to a resident with an upper extremity impairment. The resident, who was admitted in May 2022 with a diagnosis of cerebrovascular disease, was observed multiple times with the adaptive call pad placed out of reach. This was noted on several occasions, including 3/20/2024 at 9:33 AM, 3/22/2024 at 12:20 PM, 1:45 PM, and approximately 4:25 PM, and 3/25/2024 at 9:20 AM. During an observation and interview on 3/25/2024 at 9:20 AM, an LPN acknowledged that the adaptive call pad was out of the resident's reach and should be placed near the resident's hands due to contractures. The LPN then placed the call pad within reach, and the resident demonstrated the ability to trigger the call light. The DON confirmed that the expectation was for the call pad to be within the resident's reach.
Failure to Complete Significant Change in Status Assessments
Penalty
Summary
The facility failed to complete a significant change in status assessment (SCSA) within 14 days after a significant change in the resident's physical or mental condition for four residents. According to the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, an SCSA is required when a resident elects or revokes the hospice benefit. The report identified that Resident ID #7, admitted with cerebrovascular disease, was admitted to hospice services on January 1, 2024, but no SCSA was completed. Similarly, Resident ID #9, with congestive heart failure, was admitted to hospice services on February 25, 2024, without an SCSA being completed. Resident ID #17, diagnosed with dementia, was admitted to hospice services on December 23, 2023, and Resident ID #30, with adult failure to thrive, was admitted to hospice services on August 6, 2023, both without the required SCSA being completed within the mandated timeframe. During an interview with the Director of Nursing Services on March 25, 2024, it was confirmed that the significant change in status assessments were not completed for the four residents mentioned. The Director acknowledged that the assessments should have been completed within 14 days of the residents' admission to hospice services, as required by CMS regulations. The failure to complete these assessments indicates a lapse in adhering to the regulatory requirements for monitoring and documenting significant changes in residents' health status.
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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