Greenwood Operations Dba Greenwood Center

Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to following a physician's order for 1 of 1 resident reviewed with orders to check blood sugars, Resident ID #2.Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 which states in part, .The physician is responsible for directing medical treatment, nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients .

Record review revealed the resident was admitted to the facility in July of 2025 with a diagnosis including, but not limited to, type 2 diabetes mellitus with diabetic nephropathy (nerve damage that affects people with diabetes).

Record review revealed an active physician's order with a start date of 7/29/2025, that states, check blood sugar four times a day for type 2 diabetes.

Record review of the resident's care plan, dated 7/29/2025, revealed the resident was insulin dependent with an intervention to assess and record his/her blood glucose levels as ordered.

Record review failed to reveal evidence that the resident's blood sugar had been checked four times daily between 7/29/2025 through 9/4/2025.Further record review of the resident's EMR of the recorded vitals, revealed that the resident's sugar was not obtained for 137 out of 152 opportunities.During a surveyor interview on 9/4/2025 at 10:50 AM with Registered Nurse, Staff A, she indicated that if a resident's blood sugars had been checked, it would be recorded in the resident's Electronic Medical Record (EMR) under the vitals section.

She indicated that she was unaware of the physician's order.

She further acknowledged that there was no record Resident ID #2's blood sugar had been checked per the physician's order.

During a surveyor interview on 9/4/2025 at 1:09 PM with the Director of Nursing Services, she was unable to provide evidence that the physician's order to check the resident's blood sugar four times a day had been followed.

During a surveyor interview on 9/4/2025 at 3:04 PM the Nurse Practitioner, Staff B, she indicated it was her expectation that the physician's order would have been followed.

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

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/04/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Greenwood Center

1139 Main Avenue Warwick, RI 02886

SUMMARY STATEMENT OF DEFICIENCIES