Greenwood Operations Dba Greenwood Center
Inspection Findings
F-Tag F0757
F 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm or potential for actual harm
**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 REDACTED] 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.
Residents Affected - Few
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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Greenwood Operations DBA Greenwood Center in Warwick, RI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Warwick, RI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Greenwood Operations DBA Greenwood Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.