Greenwood Operations Dba Greenwood Center

Ensure each resident’s drug regimen must be free from unnecessary drugs.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it has been determined that the facility failed to ensure that the resident's drug regimen is free from unnecessary medication for 1 of 6 residents reviewed for medication administration, Resident ID #1.

Findings are as follows:

Record review of a community reported complaint submitted to the Rhode Island Department on Health on 8/13/2025 alleged, that a Medication Technician administered Resident ID #1 medications that are prescribed to his/her roommate, Resident ID #2.

The medications administered were noted to be Donepezil (a medication prescribed to treat dementia associated with Alzheimer's disease), Namenda (medication prescribed to treat moderate-to-severe Alzheimer's disease), Senna (a stimulant laxative), and Plavix (a medication prescribed to prevent blood clots).

Record review revealed Resident ID #1 was admitted to the facility in September of 2021 with diagnoses including, but not limited to, chronic kidney disease stage 3 (a moderate loss of kidney function), anemia (a blood disorder in which the blood has a reduced ability to carry oxygen), essential hypertension (persistently high blood pressure) and unspecified dementia with anxiety.

Record review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 4 out of 15, indicating a severe cognitive impairment.Review of Resident ID #1's MAR failed to reveal evidence of physician's orders for Donepezil, Namenda, Senna, and Plavix.

Record review of Resident ID #2's August 2025 MAR revealed in part, the following prescribed medications were signed off as administered on 8/12/2025: Donepezil 10 mg one time a day at 4:00 PM.

Namenda 10mg 10 mg by one time at 4:00 PM.

Plavix 75 mg one time a day at 4:00 PM initiated.

Record review of Resident ID #1's electronic medical record revealed a progress note dated 8/13/2025 at 2:03 AM, authored by Registered Nurse, Staff B, revealed in part, Medication Technician, Staff A, had administered Resident ID #1 the prescribed evening medications intended to his/her roommate, Resident ID #2.

Following the incident Residents ID#1's medical provider was contacted; a recommendation was made to monitor Resident ID #1's condition for 72 hours.During a surveyor interview with Registered Nurse, Staff B, on 8/14/2025 at 12:14 PM, she revealed that on the evening of 8/12/2025, she handed a medication cup containing Donepezil 10mg, Namenda 10mg, 2 senna tablets, and Plavix 75 mg, the prescribed evening doses of medication for the residents roommate to Staff A, with instructions to administer to them to the resident in the bed by the window.

Staff B further stated that following the administration, Staff A revealed that she had administered the above medications to the resident in the bed by the door.During a surveyor interview on 8/14/2025 at 12:34 PM, the Director of Nurses acknowledged that Resident ID #1 had received unnecessary medications on the evening of 8/12/2025.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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