Greenwood Operations Dba Greenwood Center
Greenwood Operations DBA Greenwood Center in Warwick, RI — inspection on August 14, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
resident's drug regimen is free from unnecessary medication for 1 of 6 residents reviewed for
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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.