Adviniacare Oakland Grove Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Woonsocket, Rhode Island.
- Location
- 560 Cumberland Hill Road, Woonsocket, Rhode Island 02895
- CMS Provider Number
- 415110
- Inspections on file
- 41
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Adviniacare Oakland Grove Llc during CMS and state inspections, most recent first.
A resident with a history of acute kidney failure experienced prolonged constipation after staff failed to initiate the facility's bowel management protocol, did not notify the provider of medication refusal or a new diagnosis of constipation, and neglected to update the care plan. These lapses resulted in severe fecal impaction, hospitalization, and the resident's subsequent decline and death.
Surveyors found that the walk-in freezer in the main kitchen was not maintaining a safe temperature, with several food items partially thawed and the ambient temperature at 28°F. The Food Service Director confirmed erratic freezer temperatures and acknowledged the need for replacement, following a complaint related to foodborne illness.
A resident with a cervical fracture did not receive a physician-ordered neck brace as required, due to the brace being unavailable and not applied over multiple shifts. Documentation confirmed the absence of the brace, and staff were unable to locate it, resulting in a failure to meet professional standards of quality.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, as the facility did not ensure adequate safeguards against physical, mental, sexual abuse, physical punishment, or neglect by any individual.
A resident with Alzheimer's disease and a wrist fracture was returned to the facility with a volar splint, but there were no physician's orders for monitoring circulation, motion, sensation (CSM), or skin integrity as required by facility policy. Staff and the provider confirmed the absence of these orders, and the deficiency continued for nearly two weeks until identified during survey.
A resident with multiple medical conditions and full cognitive function experienced a fall and repeatedly requested hospital transfer due to pain. The facility did not honor these requests because there was no physician order, leading the resident to call 911 independently. The resident was subsequently diagnosed at the hospital with a lumbar vertebra and rib fracture.
A resident with diagnoses of hypernatremia, dehydration, and sepsis pneumonia did not receive prescribed antibiotic therapy due to unavailability, and the facility failed to monitor urine output as ordered. The resident's condition worsened, leading to hospitalization. Staff interviews revealed a lack of awareness and documentation regarding the resident's care.
A resident on Enhanced Barrier Precautions due to a gastrostomy tube and Foley catheter was not provided care in compliance with infection control protocols. Staff failed to wear required PPE during high-contact activities, and a tube feeding syringe was not replaced daily as ordered, with the last replacement recorded 10 days prior. Additionally, a nebulizer mask was improperly stored on the floor and not changed weekly as required.
A resident did not receive prescribed antibiotic therapy after hospital discharge due to unavailability of the medication. The MAR indicated the antibiotic was unavailable on two occasions, and an LPN could not recall administering it. The DNS confirmed the medication was not in the facility until the day after it was documented as given.
A resident was mistakenly administered Clozaril, intended for another resident, due to an LPN preparing medications for two residents simultaneously and being interrupted. The resident, with a history of cirrhosis and alcoholic cardiomyopathy, exhibited overdose symptoms and required critical care interventions after being transferred to a hospital. The facility's medication administration policy was not followed, leading to this significant error.
A resident with severe cognitive impairment was potentially given the wrong medication, Clozaril, instead of their prescribed medications, leading to a change in mental status. The LPN responsible for administering the medication did not immediately evaluate the resident or document follow-up evaluations, as required by facility policy. The resident was eventually transferred to a hospital, but the on-call provider was not contacted immediately after the error was suspected.
A resident with a history of paranoid personality disorder and anxiety reported non-consensual sexual contact with another resident, despite initially describing the relationship as consensual. The resident expressed discomfort to staff members, who failed to recognize the situation as potential abuse and did not take action to ensure the resident's safety. The resident was later treated for potential sexual assault, highlighting a deficiency in the facility's protection measures.
A facility failed to recognize and investigate potential abuse when a resident expressed discomfort and fear regarding a sexual relationship with another resident. Despite the resident's intact cognition, staff did not identify the situation as potential abuse and advised the resident to speak to the Director of Social Services later. This inaction led to further non-consensual encounters, resulting in the resident being treated for potential sexual assault. The facility administrator admitted the staff's failure to protect the resident and initiate an investigation.
The facility failed to maintain an effective infection prevention and control program during a COVID-19 outbreak. Employees and visitors were not screened for symptoms, and staff did not wear required N95 masks or conduct twice-weekly testing. Additionally, nursing students did not follow Enhanced Barrier Precautions for a resident with MRSA, failing to wear gowns during high-contact activities.
The facility failed to document intake and output (I&O) as ordered by physicians for four residents with conditions requiring close monitoring, such as suprapubic catheters and kidney disease. Records showed significant gaps in I&O documentation, and staff interviews confirmed the orders were not followed.
The facility failed to monitor and address significant weight changes in three residents, resulting in unreported and unverified weight loss or gain. A resident experienced severe weight loss without proper documentation or notification to the RD and physician. Another resident had a significant weight gain without a reweigh or communication to the RD and Nurse Practitioner. A third resident's weight loss was not reweighed, contrary to policy, indicating systemic issues in weight monitoring.
A facility failed to provide trauma-informed care to a resident with PTSD, bipolar disorder, and anxiety disorder. Despite the resident's intact cognition, the facility did not complete a comprehensive assessment to identify trauma history or preferences to mitigate triggers. Staff interviews revealed a lack of awareness about the resident's trauma history and potential triggers, and a recommendation to obtain psychiatric records was overlooked.
A facility failed to elevate a resident's head to the required 30-45 degrees for one hour after G-tube feeding, as per physician's orders. The resident, with dysphagia and Alzheimer's, was observed with their bed not elevated post-feeding. Both an LPN and the DON acknowledged the oversight, indicating non-compliance with the facility's enteral feeding policy.
A resident with rheumatoid arthritis did not receive Humira as prescribed on three occasions due to pharmacy delivery issues. The MAR showed missed doses, and there was no evidence that the physician was informed. The ADON and DON acknowledged the oversight during an interview.
A resident with a history of DVT and recent hip surgery experienced increased leg swelling, but the facility failed to monitor the condition or follow care plan interventions. Despite signs of excessive swelling and pain, an ultrasound to rule out DVT was delayed until recommended by the resident's surgeon. Additionally, the facility did not obtain the resident's weight as ordered, which could have helped monitor the condition. Staff interviews revealed a lack of documentation and monitoring, contributing to the deficiency.
The facility failed to protect residents from physical abuse, as evidenced by an incident where a resident with severe cognitive impairment and a history of aggression was found with their hands around another resident's neck. Despite previous incidents and care plan notes indicating potential aggression, the facility did not effectively prevent the assault, resulting in physical harm to the victim.
A facility failed to maintain an infection prevention and control program for a resident with a Multidrug-resistant Organism (MDRO). The resident was not placed on contact precautions in a timely manner, and there was no signage indicating the need for PPE during high-contact care activities until much later. The deficiency was identified through surveyor observations and staff interviews.
Failure to Follow Bowel Management Protocol and Notify Provider Leads to Resident Harm
Penalty
Summary
The facility failed to adhere to its established bowel management protocol for a resident who experienced prolonged constipation. According to the facility's policy, if a resident has no bowel movement for 9 consecutive shifts, a specific bowel protocol must be initiated, starting with Milk of Magnesia (MOM), followed by a Bisacodyl suppository, and then a Fleet enema if needed, with results documented and the provider notified if the protocol is ineffective. Record review showed that the resident went 15 consecutive shifts without a bowel movement, and the bowel protocol was not initiated as required. When MOM was eventually offered and refused by the resident, there was no evidence that this refusal was reported to the provider for further instruction or adjustment of the care plan. Further review revealed that after the resident was sent to the hospital for stroke-like symptoms and returned with a new diagnosis of constipation, the provider was not notified of this new diagnosis to allow for appropriate care plan adjustments. Documentation also failed to show timely reassessment or updates to the care plan in response to the resident's ongoing constipation and new medical findings. Staff interviews confirmed lapses in communication and monitoring, including failure to generate and pass along the required bowel management lists between shifts and lack of provider notification regarding medication refusal and significant changes in the resident's condition. As a result of these failures, the resident developed severe fecal impaction, abdominal distention, and was ultimately hospitalized with a diagnosis of constipation and stercoral colitis. The resident's condition deteriorated further during the hospital stay, leading to hypotension, hypoxia, and death. The facility was unable to provide evidence that its bowel management protocol was followed or that appropriate notifications and interventions were made in accordance with its own policies.
Failure to Maintain Walk-In Freezer in Safe Operating Condition
Penalty
Summary
Surveyor observation and staff interview revealed that the facility failed to maintain the walk-in freezer unit in the main kitchen in a safe operating condition. During the initial kitchen tour, the freezer was found to be holding at an ambient temperature of 28 degrees Fahrenheit, and several food items, including chicken wings, chicken tenders, lobster, and pork sausage patties, were observed in a partially thawed state. The Food Service Director acknowledged both the improper freezer temperature and the fact that the items were not frozen solid, further indicating that the freezer temperatures had been erratic recently and that the unit was in need of replacement. This deficiency was identified in connection with a community-reported complaint regarding concerns of foodborne illness among residents.
Failure to Provide Physician-Ordered Neck Brace
Penalty
Summary
A deficiency occurred when a resident with a type 2 odontoid fracture, admitted in October 2025, did not receive a physician-ordered neck brace as required. The physician's order specified that the neck brace should be applied at all times, but record review showed that the brace was not available and not applied during multiple shifts over two consecutive days. Documentation from the Treatment Administration Record confirmed the absence of the neck brace during these periods, and a Physical Therapy progress note indicated that the brace was not on the resident and could not be located by nursing staff. During an interview, the Director of Nursing Services acknowledged that her expectation was for the neck brace to be applied as ordered.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Ensure Splint Care Met Professional Standards
Penalty
Summary
The facility failed to ensure that a resident with a volar splint received care in accordance with professional standards and the facility's own policy. The resident, who had Alzheimer's disease and sustained a distal radial (wrist) fracture following a physical altercation, was admitted with a splint on the left wrist. Facility policy required that residents with splints have their affected extremity monitored for circulation, motion, and sensation (CSM), as well as for signs of edema, redness, irritation, or pressure areas, at least every shift. However, record review showed there were no physician's orders in place for monitoring CSM and skin integrity for this resident after the splint was applied. Surveyor observations and staff interviews confirmed that neither the LPN nor the DON were aware of any such orders being in place, despite acknowledging that they should have been. The resident's provider also confirmed the absence of orders for monitoring CSM and skin integrity, although she would not confirm if CSM monitoring was necessary per policy. The deficiency persisted for 13 days after the resident returned to the facility with the splint, until it was identified by the surveyor.
Failure to Honor Resident's Request for Hospital Transfer After Fall
Penalty
Summary
A resident with a history of stroke, renal disease, and diabetes, who was cognitively intact and required a walker, experienced an unwitnessed fall in their room. Following the fall, the resident repeatedly requested to be transported to the hospital due to pain. Nursing progress notes indicate that the Medical Director was notified of the fall but did not provide an order for hospital transfer. Despite the resident's continued requests for hospital evaluation, the facility did not honor these requests because there was no physician order. Subsequently, the resident used their personal cell phone to call 911 and was transported to the hospital by Emergency Medical Services, where they were diagnosed with a closed fracture of the first lumbar vertebra and a rib fracture. The Director of Nursing Services confirmed during an interview that the expectation is to contact the physician if a resident complains of pain and acknowledged that she would have called for a hospital evaluation in such a case. However, she was unable to provide evidence that the facility honored the resident's request for transfer.
Failure to Administer Antibiotics and Monitor Urine Output
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding the administration of prescribed antibiotic therapy and monitoring of urine output. The resident, who had been hospitalized multiple times within a month, was readmitted to the facility with diagnoses of hypernatremia, dehydration, and sepsis pneumonia. Upon readmission, there was a physician's order to continue antibiotic therapy with Amoxicillin-Pot Clavulanate, which was not administered as prescribed due to the medication being unavailable. The medication was documented as unavailable for administration on two occasions, and the physician was not informed promptly to consider alternative treatment options. Additionally, the facility failed to monitor the resident's urine output as per the physician's order and facility policy. The resident had an indwelling foley catheter, and there was an order to document intake and output every shift for 72 hours. However, there was no evidence of such documentation from the time of the resident's readmission. Interviews with staff confirmed the lack of documentation and monitoring of the resident's urine output. The deficiency was further highlighted by the resident's deteriorating condition, as noted in a hospital assessment, which indicated lethargy, non-responsiveness, and laboratory results showing hypernatremia and acute kidney injury. The assessment also noted the possibility of incomplete treatment of pneumonia due to missed antibiotic doses. Interviews with the facility's physician and Director of Nursing Services revealed a lack of awareness and uncertainty regarding the administration of the antibiotic and monitoring of the resident's condition.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. A resident, who was readmitted with conditions including hypernatremia, dehydration, and sepsis pneumonia, was placed on Enhanced Barrier Precautions (EBP) due to the presence of a gastrostomy tube and an indwelling Foley catheter. Despite signage indicating the need for gown and gloves during high-contact care activities, a nursing assistant was observed providing care without wearing a gown on two separate occasions. The Director of Nursing Services acknowledged the expectation for staff to adhere to the facility's EBP policy. Additionally, the facility failed to adhere to physician orders regarding the replacement of a tube feeding syringe. A surveyor observed an undated syringe with dry, crusted debris on the resident's side table, which had been used to administer medications. The last recorded replacement of the syringe was approximately ten days prior, contrary to the expectation of daily replacement. The Director of Nursing Services confirmed the expectation for the syringe to be changed every 24 hours. Furthermore, the resident's nebulizer mask was found on the floor, with tubing dated 13 days prior, indicating it had not been changed weekly as required. The staff acknowledged the mask should not have been on the floor and should have been stored properly. The Director of Nursing Services confirmed the expectation for the nebulizer mask and tubing to be changed every seven days.
Failure to Administer Prescribed Antibiotic and Maintain Accurate Records
Penalty
Summary
The facility failed to maintain the resident's medical record in accordance with accepted professional standards and practices for one resident. The issue was identified through a review of two community-reported complaints submitted to the Rhode Island Department of Health, which alleged that the resident did not receive prescribed antibiotic therapy after being discharged from the hospital. The resident was readmitted to the facility with diagnoses including hypernatremia, dehydration, and sepsis pneumonia. A hospital Continuity of Care document indicated a physician's order for Amoxicillin-Pot Clavulanate to be administered twice daily for three days. However, the facility's Medication Administration Record (MAR) showed that the medication was unavailable for administration on two occasions. During interviews, a Licensed Practical Nurse (LPN) was unable to recall administering the antibiotic as documented, and the Director of Nursing Services (DNS) confirmed that the medication was not available in the facility until the day after it was supposedly administered. This discrepancy indicates a failure in maintaining accurate medical records and ensuring the availability of prescribed medications, leading to the deficiency noted in the report.
Medication Error Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving the administration of Clozaril, an antipsychotic medication, to the wrong resident. Resident ID #1, who did not have a physician's order for Clozaril, was mistakenly given the medication intended for Resident ID #2. This error occurred when Licensed Practical Nurse (LPN) Staff A prepared medications for both residents simultaneously and was interrupted by another resident, leading to the administration of the wrong medication. Resident ID #1, who had a history of cirrhosis and alcoholic cardiomyopathy, was admitted to the facility with severely impaired cognition. After receiving the incorrect medication, Resident ID #1 exhibited symptoms of a medication overdose, including difficulty arousing, low blood oxygen levels, and respiratory distress. The resident was transferred to an acute care hospital, where they required critical care interventions, including intubation and treatment for acute toxic encephalopathy and acute respiratory failure. The facility's medication administration policy, which requires verifying medication orders, identifying residents, and avoiding distractions, was not followed by Staff A. The Director of Nursing Services acknowledged that the policy was not adhered to, as Staff A prepared and administered medications for more than one resident at a time. This failure to follow protocol resulted in a significant medication error, placing Resident ID #1 at risk for serious harm.
Failure to Evaluate Resident After Suspected Medication Error
Penalty
Summary
The facility failed to meet professional standards of quality by not evaluating a resident immediately after a suspected medication error. Resident ID #1, who has a history of cirrhosis and alcoholic cardiomyopathy, was potentially given Clozaril, an antipsychotic medication intended for another resident, leading to a change in mental status. The incident was reported to the Rhode Island Department of Health, and the resident was transferred to an acute care hospital. The facility's policy requires an immediate evaluation of the resident in relation to the nature of the error, but there was no evidence that such an evaluation occurred. Staff A, an LPN, was responsible for administering medications to Resident ID #1 and another resident. During the medication pass, she was interrupted and suspected that she might have administered the wrong medication. Although she checked on the resident several times and took vital signs, there was no documentation of an immediate evaluation or follow-up evaluations. The Nurse Practitioner confirmed that the on-call provider was not contacted immediately after the error was suspected, and the Director of Nursing Services could not provide evidence of the required evaluations.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by the events involving Resident ID #1 and Resident ID #2. Resident ID #1, who was admitted with diagnoses including paranoid personality disorder and anxiety, initially reported a consensual relationship with Resident ID #2. However, Resident ID #1 later reported non-consensual sexual contact occurring over several days. Despite having a BIMS score indicating intact cognition, Resident ID #1 expressed feeling unsafe and uncomfortable with the relationship. On the morning of 9/30/2024, Resident ID #1 reported to the Director of Social Services that sexual activity had occurred without consent. Prior to this, on 9/29/2024, Resident ID #1 had expressed discomfort to staff members, including a laundry aide and a nursing assistant, about the pace of the relationship with Resident ID #2. Both staff members encouraged Resident ID #1 to speak with the Director of Social Services but did not recognize the situation as potential abuse. The concerns were communicated to an LPN, who also did not investigate further. The facility's failure to act on Resident ID #1's expressed concerns resulted in a lack of intervention to ensure safety. Resident ID #1 was later transferred to a hospital for evaluation related to genital pain and reported being treated for potential sexual assault. The facility's staff did not initiate any interventions from the time they were made aware of the resident's discomfort until the allegations of sexual assault were made, indicating a deficiency in protecting the resident from abuse.
Failure to Recognize and Investigate Allegations of Abuse
Penalty
Summary
The facility failed to recognize and investigate allegations of potential abuse involving a resident who expressed concerns about a consensual sexual relationship with another resident. Despite the resident's intact cognition, as indicated by a BIMS score of 14 out of 15, staff members did not identify the resident's discomfort and fear as potential abuse. The resident reported feeling uncomfortable and pressured by the other resident, but staff members, including a laundry aide and a nursing assistant, did not take immediate action to investigate or report the concerns to the appropriate authorities. Instead, they advised the resident to speak to the Director of Social Services the following day. The facility's inaction resulted in the resident experiencing further non-consensual sexual encounters, leading to a visit to the emergency room for potential sexual assault. The resident reported being penetrated with an object and experienced symptoms such as dysuria, pelvic pain, and anxiety. The facility administrator acknowledged that the staff did not recognize the situation as potential abuse and failed to protect the resident from further harm during the investigation. The facility did not initiate an investigation to determine if abuse had occurred, nor did they provide evidence of measures taken to prevent further incidents.
Infection Control Deficiencies During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during a COVID-19 outbreak. Despite the facility's policy to follow CDC and local public health authority guidelines, surveyors observed that employees and visitors were not screened for COVID-19 symptoms upon entering the building. Interviews with staff confirmed that screening had not been conducted for several weeks. Additionally, the facility did not adhere to the local public health authority's recommendations, which included screening, wearing N95 masks in resident care areas, and conducting COVID-19 testing twice a week for staff and residents. Further deficiencies were noted in the use of Personal Protective Equipment (PPE). A nursing assistant was observed entering a COVID-19 positive resident's room wearing two surgical masks instead of the required N95 mask, despite clear signage indicating the necessary PPE. The facility's Director of Nursing Services and other staff acknowledged the failure to follow the facility's policy and public health recommendations, including the lack of evidence for twice-weekly COVID-19 testing for staff. The facility also failed to implement Enhanced Barrier Precautions for a resident with a history of Methicillin-resistant Staphylococcus aureus (MRSA). Nursing students were observed assisting the resident with high-contact activities without wearing gowns, contrary to the facility's policy and posted signage. The Infection Preventionist confirmed the expectation for staff and visitors to adhere to infection control practices, including wearing all required PPE for rooms under isolation precautions.
Failure to Document Intake and Output as Ordered
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by not following physicians' orders for documenting intake and output (I&O) for four residents. Resident ID #26, who was readmitted with a suprapubic catheter, had a physician's order to document I&O every shift, but records from September 1 to September 10, 2024, showed that documentation was missing for 27 out of 30 opportunities. The Director of Nursing Services (DNS) could not provide evidence that the order was followed. Similarly, Resident ID #30, with a suprapubic catheter and chronic conditions, had a physician's order for I&O documentation every shift, but records showed missing documentation for 26 out of 30 opportunities. Resident ID #61, also with a suprapubic catheter, had no I&O documentation for 30 out of 30 opportunities. Lastly, Resident ID #104, with acute kidney injury and chronic kidney disease, had incomplete I&O documentation, with missing entries for 9 out of 10 opportunities on the night shift. Staff interviews confirmed the failure to follow physician's orders for I&O documentation.
Failure to Monitor and Address Significant Weight Changes
Penalty
Summary
The facility failed to ensure that residents maintained acceptable nutritional status, as evidenced by significant weight loss or gain in three residents. Resident ID #76 experienced a severe weight loss of 11.89% within a month, with missing weight documentation for two weeks in August 2024. The Licensed Practical Nurse (LPN) and Registered Dietitian (RD) were not informed of the weight loss, and the physician was also unaware until the surveyor's intervention. The Director of Nursing Services (DNS) confirmed the lack of evidence for weekly weights and the absence of reweighs following significant weight changes. Resident ID #96 showed a significant weight gain of 10.55% in less than 30 days, with no reweigh conducted as per facility policy. The weight gain was not reported to the RD or the Nurse Practitioner, indicating a communication breakdown in the facility's weight monitoring process. The nurse responsible for documenting and reporting weight changes could not provide evidence of compliance with the policy. Resident ID #104 experienced a weight loss of 17.1 lbs. in less than a month, with no reweigh conducted to verify the change. The LPN and DNS acknowledged the failure to obtain a reweigh, and the RD expected staff to follow the policy for significant weight changes. These deficiencies highlight a systemic issue in the facility's adherence to its weight monitoring policy, resulting in unaddressed significant weight changes in residents.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care to a resident with a history of PTSD, bipolar disorder, and anxiety disorder. The resident, who was admitted in October 2023, had an intact cognition score of 14 out of 15 on the Minimum Data Set assessment. Despite this, the facility did not complete a comprehensive assessment to identify the resident's specific trauma history or preferences to mitigate triggers that could cause re-traumatization. The Social Service Trauma-Informed Care Screening Tool used did not specify the type of trauma experienced by the resident or the necessary preferences to avoid triggers. Interviews with staff, including a Medication Technician, LPNs, and the Social Worker, revealed a lack of awareness regarding the resident's trauma history and potential triggers. Additionally, the Social Worker was unaware of a recommendation from Optum Behavioral Health to obtain the resident's outpatient psychiatric records. The Director of Nursing Services expressed an expectation for a completed Trauma-Informed Care Assessment for residents with PTSD, which was not fulfilled in this case.
Failure to Elevate Resident's Head Post-Feeding
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube (G-tube) received appropriate treatment and services to prevent complications. The resident, who was readmitted to the facility in February 2024 with diagnoses including dysphagia and Alzheimer's disease, had a physician's order to have their head elevated 30-45 degrees during feeding and for one hour after gravity feeds. Additionally, the resident was to be elevated at all times with continuous feeding. However, during a surveyor observation on September 11, 2024, it was noted that the resident's head of the bed was not elevated to the required position for one hour after receiving therapeutic nutrition. The surveyor's interview with a Licensed Practical Nurse (LPN) revealed that the resident completed their therapeutic nutrition at approximately 8:30 AM, but the head of the bed was not elevated as ordered. The Director of Nursing Services also acknowledged that the resident's head of the bed should have been elevated to 30-45 degrees for one hour after receiving the nutrition. This oversight indicates a failure to adhere to the physician's orders and the facility's policy on enteral feeding, potentially compromising the resident's care.
Failure to Administer Humira as Prescribed
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding the administration of Humira, a medication used to treat rheumatoid arthritis. The resident, who was admitted in March 2024 with diagnoses including infection following a surgical procedure, rheumatoid arthritis, and diabetes, had physician orders for Humira to be administered subcutaneously every two weeks. However, the Medication Administration Records (MAR) for March, April, May, and June 2024 revealed that the resident did not receive the medication on three occasions: March 29, April 12, and June 13, 2024. The progress notes indicated that on the dates the medication was missed, staff documented that they were waiting for the pharmacy to deliver the medication. There was no evidence in the records that the physician was informed about the missed doses. During an interview with the Assistant Director of Nursing and the Director of Nursing Services, it was acknowledged that the resident did not receive Humira as prescribed, and it was expected that the nurses should have notified the physician of the missed doses.
Failure to Monitor Resident's Condition and Follow Care Plan
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. The resident, who had a history of deep vein thrombosis (DVT) and recent surgery for a left hip fracture, exhibited increased swelling in the left leg. Despite this, the facility did not adequately monitor the resident's condition or follow physician's orders for weekly weight checks. The resident's care plan included interventions such as applying compression stockings and monitoring for signs of DVT, but there was no evidence that these measures were implemented. The resident was readmitted to the facility with severe non-pitting edema in the left leg. Over several days, physical therapy notes indicated excessive swelling and pain, yet the facility did not conduct an ultrasound to rule out DVT until it was recommended by the resident's surgeon. The resident's condition worsened, leading to a positive DVT diagnosis and transfer to an acute care hospital for further treatment. Interviews with staff revealed a lack of documentation and monitoring, with the nurse practitioner acknowledging the delay in ordering an ultrasound despite the resident's history and symptoms. Additionally, the facility failed to obtain the resident's weight as ordered, which could have assisted in monitoring the resident's condition and the effectiveness of prescribed medication. The Assistant Director of Nursing and Medical Director both acknowledged the expectation for nursing staff to monitor the resident's weight and condition as per the care plan. The lack of adherence to the care plan and physician's orders contributed to the deficiency in the resident's care.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect and keep residents free from physical abuse, as evidenced by an incident involving two residents. A nursing assistant observed Resident ID #1 with their hands around Resident ID #5's neck. The residents were immediately separated, and Resident ID #1 was sent to the hospital for evaluation. Resident ID #5 was later found with a bruise on their left shoulder and superficial nail marks on their neck. The facility's policy on abuse prevention was not effectively implemented to prevent this incident. Resident ID #1, who has severe cognitive impairment due to Alzheimer's disease, generalized anxiety disorder, and major depressive disorder, had a history of physical aggression. Despite being followed by psychiatric services and having medication adjustments, Resident ID #1's care plan noted the potential for physical aggression. The resident had previously been involved in an incident with Resident ID #5, leading to their separation into different rooms. However, on the day of the incident, Resident ID #1 entered Resident ID #5's room and physically assaulted them. Resident ID #5, who also has severe cognitive impairment and is dependent on assistance for most functional abilities, was unable to defend themselves. The Director of Nursing Services acknowledged that Resident ID #5 was not kept free from abuse, as required by the facility's policy. The incident highlights a failure in monitoring and ensuring the safety of residents with known aggressive behaviors, leading to physical harm to Resident ID #5.
Failure to Maintain Infection Control for MDRO
Penalty
Summary
The facility failed to maintain an infection prevention and control program to prevent the transmission of communicable diseases and infections for a resident diagnosed with a Multidrug-resistant Organism (MDRO). The resident, who was readmitted to the facility with multiple diagnoses including Alzheimer's disease and metastatic colon cancer, was found to be positive for Extended-spectrum beta-lactamase (ESBL) in the urine. Despite the CDC guidelines and the facility's own policy requiring contact precautions for residents with MDRO, the resident was not placed on contact precautions until a day after starting antibiotics, and there was no signage indicating the need for personal protective equipment (PPE) during high-contact care activities until much later. Surveyor observations revealed that the resident's room lacked appropriate signage for contact or enhanced precautions, and the resident's physician was not consulted regarding the removal of these precautions. The Infection Preventionist acknowledged that the resident was no longer on contact precautions despite the ongoing risk. It was only after the surveyor's intervention that the resident was placed on Enhanced Barrier Precautions, with proper signage and PPE availability at the doorway. This delay in implementing and maintaining appropriate infection control measures led to the deficiency noted in the report.
Latest citations in Rhode Island
A cognitively impaired resident with dementia and severe BIMS impairment, care planned and ordered to wear a wander guard with regular placement and function checks, eloped from the facility after being last seen in an activity room with a visitor. Staff later could not locate the resident for dinner, and searches were initiated while the resident’s whereabouts were unknown for several hours. Witnesses, including the Activities Director, Receptionist, another resident’s family member, and the visitor, reported that the resident and visitor exited through the main entrance without a wander guard alarm sounding and without use of a door code. The visitor admitted driving the resident to the spouse’s home without notifying staff. EMS and hospital records documented that the resident had been missing for several hours, was confused, could not recall events, and reported severe throat and chest pain, arriving at the hospital with an ankle monitoring device in place. Upon the resident’s return, the facility discarded the original wander guard without testing its functionality and could not provide evidence of consistent monitoring per policy and physician orders, resulting in an Immediate Jeopardy situation.
A resident with Alzheimer’s disease, dementia, severe cognitive impairment, documented exit-seeking behavior, and a care plan identifying high elopement risk and the use of a wander guard was inadequately supervised. Earlier in the day, an LPN observed the resident attempting to open an exit door and redirected the resident, who was later last seen in their room. The resident subsequently exited a secured unit through a stairwell door that only briefly alarmed and was not connected to the wander guard system, descended to a basement level, and left through an exterior door. Because wander guard sensors were only placed at elevators and not at exit doors or stairwells, the resident’s departure went undetected until a Code Orange was called and the elopement protocol initiated, after which staff located the resident off premises and returned the resident to the facility.
A cognitively intact resident with spinal stenosis and post-stroke hemiplegia/hemiparesis was discharged from the hospital with documented referrals to a spine center for evaluation and possible spinal steroid injections, which were reiterated in a later provider note citing ongoing lower extremity weakness. Despite these physician-ordered referrals and the resident’s repeated attempts to reach the appointment scheduler, the facility did not schedule or facilitate the neurosurgical consultation. The unit secretary, who was responsible for scheduling, reported being unaware of the referrals, and neither she nor the DON could provide any evidence that efforts were made to arrange the appointment, leading to a prolonged delay in the resident’s surgical follow-up.
A resident with dysphagia, autonomic dysfunction, seizure disorder, a G-tube, and dependence on staff for feeding had physician orders and a care plan requiring a minced and moist diet with thin liquids given by spoon only while upright. Video from a room camera showed a nurse providing thin liquids through a straw while the resident was lying down and continuing despite the resident coughing. Additionally, a physician ordered every-shift monitoring and documentation of vital signs, including lung sounds, O2 saturation, temperature, and signs of aspiration for seven days, but the MAR showed that required vital signs were not obtained on multiple shifts. The DON confirmed these deviations from physician orders and expected practice.
A resident with intact cognition and a history of hypertension used the call light for toileting assistance when a CNA entered the room and yelled statements such as not "playing games" and telling the resident to wait, causing the resident to become upset. A nursing supervisor heard the CNA yelling, went to the room, and observed the resident visibly upset, while an LPN’s written statement described the CNA’s tone as very rude and yelling about having been with another resident. The CNA later acknowledged speaking loudly to the resident, and during interviews, the administrator and DON could not demonstrate that the resident had been free from verbal abuse as required by the facility’s abuse prohibition policy.
A resident with Alzheimer’s disease receiving hospice services was observed by an RN to be grimacing, with swelling and bruising of the right ankle, and an x-ray later confirmed displaced fractures of the medial and lateral malleolus. Facility policy required that responsible family or legal representatives be notified within 24 hours of significant condition changes or injuries and that this notification be documented in the medical record. A NP documented the fracture findings and ordered that hospice and the resident’s representative be contacted, but there was no documentation that the representative was notified. In interviews, the resident’s representative reported learning of the injuries from hospice staff, the RN acknowledged not notifying the representative, and the DON could not provide evidence that immediate notification occurred, resulting in a deficiency for failure to notify the representative of a significant change in condition.
A resident with Alzheimer's disease, severe cognitive impairment, and non-ambulatory status, receiving hospice care, was found grimacing with swelling and bruising to the right ankle after being brought to the dining room. An x-ray later confirmed acute to subacute displaced fractures of both the medial and lateral malleolus, with no cause identified in the record, making it an injury of unknown origin. A hospice aide reported that during care, the resident became agitated and flailed while two CNAs held the resident's arms and legs, but care was not stopped and the nurse was not notified of the behavior. The RN on duty could not show that the injury of unknown origin was reported to RIDOH, and the DON acknowledged that the incident was not reported, resulting in a failure to report an alleged violation and injury of unknown origin as required.
A non-ambulatory hospice resident with severe cognitive impairment developed swelling and bruising of the right ankle after being taken to the dining room and receiving care in the room, during which the resident became agitated and flailed while a hospice aide and two CNAs continued care and physically held the resident’s arms and legs. An RN later noted the ankle changes, obtained an x-ray order from a provider, and imaging confirmed acute to subacute displaced fractures of both the medial and lateral malleolus. The clinical record and interviews with the RN, DON, and NP showed that no thorough investigation was conducted into the origin of the injury, no potential causes were documented or identified, and no interventions to prevent further or potential injury were documented, despite regulatory requirements and a community complaint alleging lack of notification and unclear cause of the injury.
A resident with CHF, afib, moderate cognitive impairment, and low body weight was mistakenly given another resident’s clozapine 150 mg and melatonin 3 mg by a CMT who entered the wrong room and failed to verify identity, contrary to facility policy requiring multiple resident-identification checks. The resident did not receive ordered warfarin and metoprolol during this pass. Subsequently, the resident was found unresponsive with abnormal respirations, tachycardia, and hypoxia, required EMS intervention with suctioning, high-flow oxygen via BVM, and IV emergency cardiac medication, and was admitted to the hospital with altered mental status, profound hypothermia, pleural effusion, and aspiration pneumonia, later transitioning to comfort care and expiring. The DON was unable to show the resident was kept free from significant medication errors, and the Medical Director stated she expected correct medications to be given to the correct resident.
The facility failed to ensure that a CMT had demonstrated competency in resident identification during medication administration and did not complete the required quarterly medication aide evaluations. Despite only one documented evaluation and no evidence of competency in verifying resident identity, the CMT was scheduled to pass medications and entered the wrong room, administering clozapine 150 mg and melatonin 3 mg intended for another resident to a frail, elderly resident with CHF and Afib. The resident, who weighed 79.2 pounds, subsequently developed tachycardia, shortness of breath, altered mental status, profound hypothermia, a small pleural effusion, and aspiration pneumonia, was admitted to the hospital for comfort measures only, and later died. The DON acknowledged that quarterly evaluations were required and could not provide evidence that the CMT had demonstrated competency in medication administration per state requirements.
Elopement of Cognitively Impaired Resident Despite Wander Guard Device
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary supervision and maintain an effective elopement prevention system for a cognitively impaired resident identified as an elopement risk. The resident had diagnoses including dementia, cognitive communication deficit, and anxiety disorder, and a Quarterly MDS showed a BIMS score of 4/15, indicating severe cognitive impairment. The resident’s care plan, initiated after prior attempts to leave the facility, required use of a wander guard bracelet, weekly assessment of the device’s functioning and battery status, and visual checks or supervision for safety. Physician orders directed staff to check placement of the Tektone wander guard bracelet every shift and to check its functionality weekly. Documentation on the March Treatment Administration Record indicated the device was in place on the day of the incident and that its functionality had been checked and found operational several days earlier. On the day of the elopement, staff observed the resident wearing the wander guard bracelet in the activities room during a bingo activity in the mid-afternoon. An LPN reported last seeing the resident in the activity room seated with a visitor and wearing the wander guard. Later, when the LPN attempted to escort the resident to dinner, the resident could not be located, and a subsequent call to the resident’s spouse confirmed that the spouse did not have the resident and was unaware the resident was missing. The facility’s elopement protocol was then initiated, and staff, along with law enforcement, conducted searches of the building and surrounding community. During this time, staff and management did not know the resident’s whereabouts for several hours. Interviews and witness accounts established that the resident exited the facility through the main entrance with a visitor. The Activities Director stated that she did not see the resident or visitor leave and did not hear a wander guard alarm at the exit. The Receptionist reported seeing the resident and a visitor walking toward the main entrance and also did not hear an alarm. A visitor later admitted that she removed the resident from the facility at the resident’s request to go home, drove the resident to the spouse’s house, dropped the resident off, and left without notifying staff; she stated that the wander guard alarm did not sound when they exited and that she had never been given a door code. A family member of another resident reported seeing the visitor leave with the resident through the main entrance without hearing an alarm or seeing a code entered. The resident ultimately arrived at the spouse’s home with a sandwich in hand, appeared confused, and could not explain how they had gotten there. EMS and hospital records documented that the resident had been missing from the facility for several hours, could not recall their whereabouts, and reported severe throat and chest pain; the hospital record also noted that the resident arrived with an ankle monitoring device in place. Following the resident’s return, the facility did not evaluate or test the wander guard device that had been in use at the time of the elopement. A Regional Nurse documented that a new wander guard device was applied to the resident’s left ankle, and later acknowledged in interview that the original device had been discarded without assessment. The Regional Administrator and Regional Nurse were unable to provide evidence that the previous device had been checked or tested for functionality upon the resident’s return. The Administrator stated that it was unclear whether the wander guard system had failed, whether an alarm had sounded without staff response, or whether a visitor had entered a door code, and confirmed that visitors should not have the door code. The facility was also unable to provide documentation confirming that staff consistently monitored the resident in accordance with facility policy and physician orders. These failures resulted in the resident leaving the facility unsupervised for approximately six hours while staff were unaware of the resident’s whereabouts, placing the resident at risk for serious injury, serious harm, serious impairment, or death, and constituted a situation of Immediate Jeopardy.
Failure of Elopement Prevention and Supervision for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and maintain an effective elopement prevention system for a resident assessed as a high elopement risk. The resident had Alzheimer’s disease, dementia, severe cognitive impairment (BIMS score of 00), a documented history of exit-seeking behaviors, and a care plan identifying high elopement risk, prior elopements, recent attempts to leave, verbalizations about leaving, and wandering behavior requiring a wander guard. On the morning of the incident, an LPN observed the resident attempting to open the unit exit door at approximately 9:30 AM; the resident was redirected and escorted back to the dining room. The resident was last seen in their room at approximately 10:00 AM. Despite residing on a secured unit and wearing a wander guard, the resident eloped from the unit via a stairwell door that alarmed when opened but stopped alarming after the door closed and after a period of time. The wander guard system was configured so that sensors were only located at the elevators and did not detect the resident at the unit exit doors or stairwell. The resident used the stairwell to descend several flights to the basement level and exited through a basement exterior door, leaving the building undetected. A Code Orange was not called and the elopement protocol not initiated until approximately 11:20 AM, at which time the resident had already traveled off premises and was later observed walking along a main road and crossing a four-lane street before being located and returned to the facility at approximately 11:45 AM.
Failure to Arrange Neurosurgical Follow-Up for Resident With Spinal Stenosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services were provided in accordance with professional standards of quality for a resident admitted with spinal stenosis and post-stroke hemiplegia/hemiparesis. The resident was admitted in October 2025 with diagnoses including spinal stenosis and left-sided weakness following a stroke. A Continuity of Care - Post-Acute Facility document dated 10/24/2025 indicated that, upon hospital discharge, a referral to a spine center was placed to evaluate the need for spinal steroid injections. A subsequent provider progress note dated 11/17/2025 documented the resident’s ongoing chronic lower extremity weakness related to lumbar disc protrusions and reiterated the need for outpatient neurosurgical follow-up, with an additional referral placed at that time. Record review and interviews showed that, despite these clear and repeated physician-ordered referrals, the facility did not schedule or facilitate the required neurosurgical consultation. The resident, who had a Brief Interview for Mental Status score of 14/15 indicating cognitive intactness and ability to express needs, reported making multiple unsuccessful attempts to contact the facility’s appointment scheduler to obtain the neurosurgical consultation for spinal injections. During an interview, the Unit Secretary responsible for scheduling appointments stated she was unaware of the referrals, and neither she nor the Director of Nursing Services could provide evidence that any efforts were made to arrange the neurosurgical appointment. A community complaint alleged that the resident waited approximately five months without resolution of the needed surgical follow-up appointment.
Failure to Follow Physician Orders for Dysphagia Management and Vital Sign Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of practice and followed physician orders for a resident with significant swallowing difficulties and other complex medical conditions. The resident, admitted with diagnoses including seizure disorder, autonomic dysfunction, presence of a gastrostomy tube, bilateral upper extremity contractures, and dysphagia, was dependent on staff for eating. A physician’s order dated 1/6/2026 specified a house diet with minced and moist texture and thin liquids to be provided by spoon only. The care plan initiated on 12/4/2024 also identified swallowing difficulty and included an intervention to provide thin liquids via spoon. A community complaint and video footage from the resident’s room showed that during an overnight shift, a nurse gave the resident a drink using a straw while the resident was lying down and continued to provide liquids while the resident was coughing, contrary to the physician’s order and care plan. The DON confirmed, after reviewing the video, that the nurse provided thin liquids with a straw while the resident was not upright and continued despite the resident’s coughing. The facility also failed to follow a physician’s order related to monitoring for possible aspiration. A physician’s order dated 3/19/2026 directed staff to obtain and document the resident’s vital signs, including lung sounds, oxygen saturation, temperature, and signs and symptoms of aspiration such as coughing or runny nose, every shift for seven days. Review of the March 2026 Medication Administration Record showed that vital signs were not obtained during the 3:00 PM–11:00 PM and 11:00 PM–7:00 AM shifts on 3/23/2026, and the 11:00 PM–7:00 AM shift on 3/24/2026. In an interview, the DON stated she expected vital signs to be obtained and documented each shift as ordered and acknowledged that the facility failed to ensure physician orders were followed for this resident.
Failure to Protect a Resident From Verbal Abuse by Nursing Assistant
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by a nursing assistant. The resident was admitted with diagnoses including hypertension and had an admission MDS Brief Interview for Mental Status score of 15/15, indicating intact cognition. On the evening in question, after the resident used the call light for toileting assistance, Nursing Assistant Staff A entered the room and yelled, "I'm not playing games with you tonight, you keep pressing the call light, and I told you to wait." The resident reported being upset by this interaction. A Nursing Supervisor, Staff B, who was on duty at the time, responded to the resident’s room after hearing Staff A yelling and observed the resident to be visibly upset. An LPN, Staff C, provided a written statement indicating she heard Staff A speaking in a very rude tone and yelling, "I told you to wait, I was with another resident." Staff A’s own written statement acknowledged that she spoke back to the resident loudly. During an interview with the Administrator and the Director of Nursing Services, they acknowledged the findings and were unable to provide evidence that the resident was free from verbal abuse during this incident, in contrast to the facility’s abuse prohibition policy defining verbal abuse as disparaging or derogatory oral, written, or gestured language within a resident’s hearing.
Failure to Notify Resident Representative of Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s representative of a significant change in condition, specifically an injury of unknown origin resulting in right ankle fractures. The facility’s policy dated 10/19/2023 requires responsible family members or legal representatives to be notified as soon as possible, or within 24 hours, of any changes in the resident’s condition, including significant physical changes and any accidents resulting in injury, with documentation of such notification in the medical record. The resident, admitted in October 2025 with Alzheimer’s disease and receiving hospice services, was observed on 3/9/2026 by an RN to be grimacing after being brought to the dining room, and further assessment revealed swelling and bruising of the right ankle. An x-ray was ordered and later confirmed acute to subacute fractures of the medial malleolus with displacement and a moderately displaced fracture of the lateral malleolus. A subsequent progress note by a nurse practitioner documented the fracture findings and included an order to contact hospice and the resident’s representative to review the results. However, record review did not show any evidence that the resident’s representative was notified by the facility of the injuries, nor was there documentation of such notification in the medical record as required by policy. During interviews, the resident’s representative stated that they were not notified by the facility and instead learned of the injuries from hospice staff. The RN who first identified the bruising and swelling acknowledged that she did not notify the resident’s representative. The Director of Nursing Services was unable to provide evidence that the resident’s representative was immediately notified when the injuries were identified, confirming the failure to follow the facility’s notification policy.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
The facility failed to timely report an injury of unknown origin to the Rhode Island Department of Health (RIDOH) for a resident with Alzheimer's disease who was non-ambulatory, dependent on staff for all transfers, and had severe cognitive impairment. The resident, who was on hospice services, was brought to the dining room by staff and was later observed grimacing, with swelling and bruising to the right ankle. An x-ray obtained that evening confirmed acute to subacute fractures of both the medial and lateral malleolus with displacement. A subsequent nurse practitioner note documented the fracture findings and included an order to contact hospice and the resident's representative, but the clinical record did not identify a cause for the injury, classifying it as an injury of unknown origin. Record review also failed to show that this injury of unknown origin was reported to RIDOH. During interviews, a hospice aide reported that after lunch she provided care to the resident in the room, accompanied by two CNAs. She stated the resident was not in discomfort before care, but became agitated during care and flailed upper and lower extremities, while one CNA held the resident's legs and another held the resident's arms; she did not stop care or notify the nurse of the resident's behavior. After care, the resident was transferred to a chair and returned to the dining room, and the aide later learned of the swollen ankle after returning from lunch, without knowing how the injury occurred. The RN on duty at the time of injury identification was unable to provide evidence that the injury of unknown origin was reported to RIDOH, and the Director of Nursing Services acknowledged that the facility did not report the injury to RIDOH, confirming the failure to report the alleged violation and injury of unknown origin as required.
Failure to Investigate Injury of Unknown Origin and Identify Cause of Ankle Fractures
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an injury of unknown origin for a non-ambulatory resident with Alzheimer’s disease who was dependent on staff for all transfers and had severe cognitive impairment. The resident, who was on hospice services, was brought to the dining room by staff and later exhibited grimacing, with swelling and bruising noted to the right ankle. An x-ray obtained the same day confirmed acute to subacute displaced fractures of both the medial and lateral malleolus. Although the nurse on duty notified the provider and obtained the x-ray order, the clinical record lacked documentation of any investigation into how the injury occurred, any determination or discussion of potential causes, or identification of the origin of the fractures. Surveyor interviews revealed that a hospice aide, accompanied by two CNAs, had taken the resident to the room after lunch to provide care. During care, the resident, who had not shown discomfort beforehand, became agitated and flailed upper and lower extremities while one CNA held the resident’s legs and another held the resident’s arms; care was continued despite the agitation, and the nurse on duty was not notified of this behavior. After care, the resident was transferred to a chair and returned to the dining room, and the hospice aide later learned of the swollen ankle but did not know how the injury occurred. The RN who discovered the swelling and bruising, the DON, and the NP all acknowledged there was no thorough investigation, no documentation establishing the origin of the injuries, and no evidence of implemented measures to prevent further or potential injury, and the facility could not provide investigative findings or evidence of required reporting.
Fatal Medication Error Due to Failure to Verify Resident Identity
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when a Certified Medication Technician (CMT) administered another resident’s medications without verifying identity. On the evening medication pass, the CMT, identified as Staff A, entered the wrong room and gave clozapine 150 mg and melatonin 3 mg, which were prescribed for a different resident, to Resident ID #1. This administration occurred despite a facility policy requiring staff to verify resident identity using methods such as checking an identification band, reviewing a photograph attached to the medical record, and, if necessary, confirming identity with other personnel. All patient identifiers were missed, and the resident did not receive his or her regularly scheduled medications, including warfarin 0.5 mg and metoprolol 12.5 mg. Resident ID #1 had been admitted in October 2025 with diagnoses including congestive heart failure and atrial fibrillation and was over a specified advanced age. A recent MDS assessment showed moderately impaired cognition with a Brief Interview for Mental Status score of 10 out of 15. The resident weighed 79.2 pounds, and the provider documented that the clozapine dose administered in error was a significant concern given the resident’s small body habitus. Record review confirmed there were no physician orders for clozapine 150 mg or melatonin 3 mg for this resident. Following the medication error, progress notes documented that late on the night of the error, the LPN (Staff B) recorded that the resident had received another resident’s medications and had missed his or her own scheduled warfarin and metoprolol. The next morning, staff found the resident unresponsive with abnormal breathing, pale skin, a heart rate of 136 bpm, and an oxygen saturation of 90%, prompting transfer via EMS. EMS records described the resident as unresponsive with audible gurgling, excessive oral secretions requiring suctioning, a fast and irregular heart rate between 150–190 bpm, and severely depressed respirations requiring bag-valve-mask support and IV emergency heart medication. Hospital records documented elevated heart rate, shortness of breath, altered mental status, profound hypothermia, a chest x-ray showing a small left pleural effusion and aspiration pneumonia, and subsequent transition to end-of-life care, with the resident expiring several days later. During interviews, the DON could not demonstrate that the resident was kept free from significant medication errors, and the Medical Director stated she would have expected the correct medications to be administered to the right resident.
Failure to Ensure CMT Medication Competency and Required Quarterly Evaluations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a Certified Medication Technician (CMT) had the required competencies and quarterly evaluations to safely administer medications, as required by Rhode Island regulations. State regulations mandate that medication technicians must complete a State‑approved course, demonstrate competency in drug administration, and receive quarterly evaluations by the Director of Nursing (DON) or RN designee, with documentation placed in personnel files. The facility’s own assessment stated that department‑specific training and competencies are completed throughout employment to ensure staff can safely and competently provide the required care. However, review of the CMT’s personnel record showed she was hired as a CMT/Nursing Assistant and had only one medication administration evaluation since hire, with no evidence of the four required quarterly evaluations. Record review of the CMT’s “Medication Administration Competency” document showed no evidence that she had demonstrated competency in identifying a resident prior to medication administration. Despite this, she was scheduled to administer medications periodically. On the evening in question, the CMT entered the wrong room and administered medications intended for another resident to Resident ID #1, without verifying the resident’s identity and missing all patient identifiers. The medications administered in error included clozapine 150 mg and melatonin 3 mg, which were prescribed for another resident. Resident ID #1 had been admitted in October 2025 with diagnoses including congestive heart failure and atrial fibrillation and was over a specified advanced age. Following the medication error, a provider note documented that the CMT had administered the wrong medications by entering the wrong room and failing to verify identity, and that the clozapine dose was of significant concern given the resident’s low body weight of 79.2 pounds. The resident subsequently presented to the hospital with elevated heart rate, shortness of breath, and altered mental status, was found to have profound hypothermia, a small left pleural effusion, and aspiration pneumonia, and was admitted for inpatient comfort measures only. The resident later expired. The DON acknowledged that medication aide evaluations are required at least quarterly and was unable to provide evidence that the CMT had demonstrated competency in medication administration per state requirements.
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