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F0610
D

Failure to Investigate Repeated Injuries of Unknown Origin

Providence, Rhode Island Survey Completed on 02-12-2026

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to investigate injuries of unknown origin for a resident with dementia who was readmitted in July 2025. The facility’s abuse prohibition policy requires that incidents be identified and followed by an incident report, supervisory follow-up, and a comprehensive internal investigation with timely notification to appropriate agencies as warranted. Clinical record review showed multiple documented injuries for this resident, including a bruise to the right forearm and elbow on 11/6/2025, left forearm discoloration and a skin tear on 11/17/2025 when the resident was unable to verbalize how the skin tear occurred, a bruise on the right arm and redness on the right elbow on 12/2/2025 when the resident could not recall or report how the injury occurred, and a bruise on the left upper arm noted by a nursing assistant on 12/27/2025. Further record review did not show any evidence that an investigation was conducted to determine the origin of these bruises and skin tears. During an interview on 1/29/2026, the Director of Nursing Services confirmed she was unable to provide evidence that an investigation had been initiated for these injuries of unknown origin.

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