Apple Rehab Clipper
Inspection history, citations, penalties and survey trends for this long-term care facility in Westerly, Rhode Island.
- Location
- 161 Post Road, Westerly, Rhode Island 02891
- CMS Provider Number
- 415120
- Inspections on file
- 24
- Latest survey
- July 8, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Apple Rehab Clipper during CMS and state inspections, most recent first.
A resident with chronic kidney disease was readmitted after hospitalization, but the facility failed to reconcile differing Aranesp orders between the hospital discharge summary and the facility's records. Neither the provider nor nursing staff ensured the correct order was implemented, and no order was in place for weekly hemoglobin monitoring as required for safe administration of Aranesp. The discrepancy was identified by pharmacy, but not promptly addressed by the care team.
Two residents experienced significant medication errors when prescribed medications, including Aranesp, Heparin, and Trazodone, were not administered as ordered. Medication administration records lacked evidence of these medications being given on multiple occasions, and there was no documentation that providers were notified of the missed doses. The DON confirmed that physician orders were not followed and could not provide evidence that the residents were kept free from significant medication errors.
A resident with a percutaneous nephrostomy tube did not consistently receive care as ordered by the physician, including missed documentation of drain output, incomplete flushing of the tube, and missed site care. These deficiencies were identified through record review and staff interview after a complaint regarding staffing and medication errors.
The facility used an outdated diet manual and failed to utilize standardized recipes with nutritional information, resulting in menus that did not meet current national guidelines for resident nutrition. Staff interviews confirmed reliance on old standards and the absence of standardized recipes, with no evidence provided that menus met residents' nutritional needs.
Surveyors found that food items in the kitchen were not properly dated or stored, equipment was not kept clean, and staff handled ready-to-eat foods without gloves. Additionally, hot meals were routinely transported uncovered through hallways to resident rooms, contrary to food safety standards. These practices were acknowledged by dietary staff and the Food Service Director as routine.
A resident with a stage 4 pressure ulcer did not receive wound care according to physician orders and infection control protocols. During a dressing change, an RN failed to remove soiled gloves or perform hand hygiene before applying a new dressing, and used a collagen sheet not ordered by the physician. The DON confirmed that proper procedures and orders were not followed.
The facility failed to maintain acceptable nutritional status for two residents who experienced significant weight loss, and did not follow its own weight monitoring policy for three residents. Interventions were not implemented after severe weight loss, required weights were missed, and physicians were not notified as per policy. Staff interviews confirmed these deficiencies in monitoring and response.
Surveyors found that two medication carts contained multiple opened inhalers and a nasal spray that were either expired or not dated as required by facility policy and manufacturer instructions. RNs acknowledged the deficiencies, and the DON could not provide evidence that expired or undated medications were removed or properly labeled.
The facility did not obtain written authorization to hold personal funds for two residents. In both cases, documentation indicated that funds should be given directly to the residents, yet the facility maintained personal funds accounts for them without the required authorization forms. The Business Office Manager could not provide evidence of proper authorization during the survey.
The facility failed to maintain nutritional status for several residents by not adhering to its weight monitoring policy. Residents experienced significant weight changes without reweighs or new interventions, despite having conditions like dementia and COPD. The DNS and staff could not provide explanations or evidence of compliance, indicating systemic issues.
The facility did not complete annual performance reviews for three nurse aides, as required. A review of personnel files showed no evidence of evaluations for Staff F, G, and H, despite their long tenure. The DON could not provide documentation of these evaluations during an interview.
A facility failed to provide appropriate care for a resident with an indwelling catheter. The resident's care plan lacked an intervention for measuring urinary output every shift, and records showed inconsistent documentation of urinary output. Interviews with staff confirmed the deficiency in monitoring, indicating a failure to ensure adequate care for the resident's catheter needs.
A resident with Alzheimer's and hypertension had a care plan for lower leg edema that included ACE wraps, but surveyors found the plan was not implemented. The resident wore non-skid socks instead, and staff were unaware of the care plan. The DON acknowledged the oversight.
A resident with Parkinson's disease and dementia did not receive weekly body audits as ordered by a physician. The audits were not documented for four out of five opportunities. A registered nurse acknowledged the oversight, and the DON could not provide evidence of completed audits.
The facility failed to address irregularities identified by the Clinical Consultant Pharmacist for two residents on antipsychotic medications. Recommendations for monitoring and documentation were not reviewed or acted upon by the provider, and there was no evidence of ongoing monitoring for specified conditions or behaviors. Interviews with staff revealed uncertainty and lack of evidence regarding the review and implementation of the pharmacist's recommendations.
A surveyor found that a facility failed to store medications properly, with an undated open vial of tuberculin and expired lorazepam bottles in the medication room. A nurse acknowledged the oversight but could not explain why expired medications were not discarded, indicating a lapse in following storage and expiration policies.
The facility failed to ensure proper infection control practices, as a nurse used a blood glucose meter on a resident without following the disinfection policy, using only an alcohol wipe instead of EPA-approved disinfectants. Additionally, the facility did not implement Enhanced Barrier Precautions for residents with indwelling medical devices, lacking necessary signage and protective equipment use by staff.
The facility did not conduct mandatory QAPI training for its staff, including RNs and NAs hired between 2000 and 2022. A review showed no evidence of completed training, and the DON could not provide proof of training during an interview.
Failure to Reconcile Medication Orders and Monitor Lab Values After Hospital Readmission
Penalty
Summary
The facility failed to ensure that a resident's medical care was properly supervised by a physician, specifically regarding the reconciliation of medication orders for Aranesp, a drug used to treat anemia in chronic kidney disease. Upon the resident's readmission following a hospitalization, there was a discrepancy between the hospital discharge order for Aranesp (25 mcg every 7 days) and the existing facility order (40 mcg every 28 days). The facility's records did not show evidence that nursing staff or providers reconciled these differing orders upon the resident's return. Both the physician and nurse practitioner documented that medications were reviewed and reconciled, but neither addressed the specific change in the Aranesp order from the hospital discharge summary. A pharmacy consultation also identified the discrepancy and requested clarification, but the issue was not promptly resolved. Additionally, there was no physician order in place to obtain weekly hemoglobin values to determine whether Aranesp should be administered or held, as required by the medication parameters. Interviews with the nurse practitioner and physician revealed that they were unaware the hospital discharge order had not been transcribed and that no order for routine hemoglobin monitoring was in place. The Director of Nursing Services confirmed that it was her expectation that both the medication order and the monitoring order should have been reconciled and implemented upon the resident's readmission.
Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the care of two residents. For one resident with chronic kidney disease, a physician's order for Aranesp 25 mcg every 7 days was not entered into the resident's record upon admission, and subsequent medication administration records showed that the medication was not given on multiple ordered dates. Laboratory results indicated that the resident's hemoglobin levels were within the range that required administration of Aranesp, yet there was no evidence that the medication was provided as ordered. Additionally, there was no documentation that the provider was notified of these missed doses, and the physician confirmed he was not informed of the missed administrations. Another resident admitted with dementia and vertebral fractures had physician's orders for Heparin and Trazodone, but the medication administration record did not show evidence that these medications were given on the day of admission. Again, there was no documentation that the provider was notified of the missed medication administrations. The Director of Nursing Services confirmed that it was her expectation that physician's orders should have been followed and was unable to provide evidence that the residents were kept free from significant medication errors.
Failure to Follow Physician Orders for Nephrostomy Tube Care
Penalty
Summary
A deficiency was identified when a resident with a percutaneous nephrostomy tube (PCN) did not receive care in accordance with physician's orders and professional standards of practice. Record review showed that the resident, admitted with an artificial opening of the urinary tract, had specific physician's orders for nephrostomy drain management, including emptying and recording output every shift, flushing the PCN with normal saline every day and evening shift, and performing PCN site care every two days. Documentation failed to show that these orders were consistently followed, with multiple instances where drain output was not recorded, the PCN was not flushed, and site care was not completed as ordered on specified dates and shifts. During an interview, the Director of Nursing Services confirmed that it was her expectation for the resident's PCN orders to be completed as prescribed. The findings were based on both record review and staff interview, and were initiated following a community complaint regarding concerns with facility staffing and medication errors.
Outdated Diet Manual and Lack of Standardized Recipes Result in Menu Deficiency
Penalty
Summary
The facility failed to provide dietary menus that meet the nutritional needs of residents in accordance with current national guidelines. Record review showed that the diet manual used by the facility was outdated, referencing the Maryland Department of Health and Mental Hygiene Diet Manual for Long Term Care Residents 2014 Revision, while the most recent national guidelines were revised in 2020. Registered Dietitians confirmed that menus are generated corporately and reviewed using the outdated manual. The Director of Nutrition Services was unaware that the manual was not current and confirmed that the facility did not use standardized recipes. Further review of menus served over a one-week period revealed no evidence of standardized recipes on file. The recipe binder available contained recipes from internet sources without caloric or nutrient information. The Food Service Director confirmed that standardized recipes were not used in meal preparation. As a result, the facility could not provide evidence that their menus met the nutritional needs of residents as required by established national guidelines.
Deficiencies in Food Storage, Handling, and Meal Distribution
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food storage, preparation, and distribution practices. In the main kitchen, opened bottles of nectar thickened juices were found either undated or dated beyond the manufacturer's recommended use period, contrary to professional standards and FDA Food Code requirements. Additionally, the microwave in the kitchen contained visible food debris, indicating a lack of proper cleaning. During meal preparation, a cook was observed assembling a sandwich with bare hands, without using gloves, which is not in accordance with food safety protocols for handling ready-to-eat foods. Further observations during meal service revealed that hot food plates were transported uncovered from the steam table to resident rooms across significant distances in both the Portside and Starboard Units. Dietary aides acknowledged that plates were only covered if residents were not eating immediately, and the Food Service Director confirmed that carrying uncovered meals was standard practice. These actions failed to protect food from potential contamination as required by professional standards.
Failure to Follow Wound Care Protocol and Infection Control During Pressure Ulcer Treatment
Penalty
Summary
A resident with a stage 4 pressure ulcer to the sacral region was readmitted to the facility with physician orders for specific wound care, including cleaning with vashe wash, packing with alginate AG, and applying a collagen sheet daily and as needed. During a dressing change observed by a surveyor, a registered nurse failed to follow infection control procedures by not removing soiled gloves or performing hand hygiene after removing the soiled dressing, and then used the same gloves to apply the clean dressing. Additionally, the nurse applied a collagen sheet containing silver, which was not the type ordered by the physician. Staff interviews confirmed that the nurse did not change gloves or perform hand hygiene as required by facility policy and professional standards of practice. The Director of Nursing Services also acknowledged that the physician's order for the wound dressing was not followed and that proper infection control procedures were not observed during the dressing change.
Failure to Maintain Nutritional Status and Adhere to Weight Monitoring Policy
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status, such as usual body weight, for two residents who experienced actual weight loss. Specifically, one resident with dementia was re-admitted and experienced a severe weight loss of 8.5% in less than one month, followed by continued weight loss in subsequent months. The Registered Dietitian assessed the resident but did not implement any interventions, citing a belief that the initial weight was an error, and there was no evidence that the resident was reweighed to verify this. Additionally, there was no documentation that the physician was notified of the severe weight loss, as required by facility policy, and further weight loss occurred without intervention. Another resident with type 2 diabetes and a history of weight loss experienced a 7.74% severe weight loss in less than one month. The care plan required weekly weights, but the facility failed to obtain weights as ordered and did not implement interventions or notify the physician after the significant weight loss. The facility's records did not show that weights were obtained upon admission or at the required weekly intervals, as per policy and physician orders. A third resident with a neurodegenerative disorder and dysphagia experienced a 5.5% weight loss, but the facility did not reweigh the resident after a 5 lbs. discrepancy as required by policy, and missed additional weekly weights as ordered. Interviews with staff, including the Director of Nursing Services and the Medical Director, confirmed that interventions were not implemented and that required weight monitoring and physician notifications were not completed. The facility failed to follow its own weight monitoring policy for three residents reviewed.
Failure to Properly Store and Label Medications on Medication Carts
Penalty
Summary
Surveyor observations and staff interviews revealed that the facility failed to store and label drugs and biologicals in accordance with professional standards and facility policy for two medication carts. On the Portside Unit medication cart, a Breo Ellipta inhaler was found opened and labeled with a date indicating it was expired, and the RN present acknowledged the inhaler was expired. The manufacturer's instructions specify that the inhaler should be discarded six weeks after opening, which was not followed. On the Starboard Unit medication cart, several inhalers and a nasal spray were found opened and not dated, including a Trelegy Ellipta inhaler, a Breyna inhaler, a Flovent inhaler, a Fluticasone propionate nasal spray, and two Albuterol inhalers. Facility policy and manufacturer instructions require these medications to be dated when opened and discarded after a specified period or number of uses. The RN present confirmed that these medications were opened and not dated. The Director of Nursing Services was unable to provide evidence that the expired inhaler was removed or that the other medications were properly dated when opened.
Failure to Obtain Written Authorization for Holding Resident Personal Funds
Penalty
Summary
The facility failed to obtain written authorization to hold personal funds for two residents. For one resident, records showed a personal funds account balance, but the only available authorization form directed that personal needs funds be given directly to the resident, with no evidence of a form authorizing the facility to hold the funds. Similarly, for another resident, the personal funds account had a balance, but the signed authorization form also directed that funds be given directly to the resident, and no documentation was found authorizing the facility to retain the funds. During an interview, the Business Office Manager was unable to provide evidence that the required authorization forms were in place for these residents.
Failure in Weight Monitoring and Nutritional Status Maintenance
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for seven out of eight residents reviewed, as evidenced by inadequate weight monitoring and failure to implement necessary interventions. The facility's policy required residents to be weighed weekly for four weeks upon admission and then monthly, with reweighs mandated for any weight discrepancy of 5 pounds or more. However, the records revealed multiple instances where residents experienced significant weight changes without reweighs being conducted, contrary to the facility's policy. For instance, one resident with a gastrostomy tube experienced a weight loss of 22.4 pounds within a short period, yet there was no evidence of a reweigh or new interventions to address the weight loss. Another resident, admitted on hospice services, did not have monthly weights recorded, and there was no physician's order to discontinue weight monitoring. Additionally, a resident with Alzheimer's Disease and paraplegia experienced a weight loss of 5.6 pounds without a reweigh, and no monthly weight was recorded for May 2024. The facility's failure to adhere to its weight monitoring policy was further highlighted by the lack of reweighs for residents who experienced weight fluctuations of 5 pounds or more. This included residents with conditions such as vascular dementia, hypertension, and chronic obstructive pulmonary disease. The Director of Nursing Services (DNS) and other staff members were unable to provide explanations or evidence of compliance with the policy, indicating a systemic issue in the facility's weight monitoring practices.
Failure to Conduct Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete an annual performance review for every nurse aide at least once every 12 months, as required. This deficiency was identified during a record review and staff interview, which revealed that the personnel files for three nursing assistants, Staff F, G, and H, lacked evidence of a completed performance evaluation within the last year. Staff F was hired on November 23, 2022, Staff G on July 17, 2007, and Staff H on December 4, 2000. During an interview with the Director of Nursing Services on May 22, 2024, she was unable to provide documentation of the required evaluations for these employees.
Inadequate Monitoring of Urinary Output for Resident with Catheter
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with an indwelling catheter. The resident, who was admitted with chronic obstructive pulmonary disease and atrial fibrillation, required a supra-pubic tube due to urinary retention. The care plan for the resident did not include an intervention for measuring and recording urinary output every shift, which is essential for assessing renal function and urinary drainage. A review of the resident's records from May 9, 2024, to May 21, 2024, showed that urinary output was documented only 9 times out of 39 opportunities. The recorded outputs varied, with several instances showing 0 ml, indicating a lack of consistent monitoring. Interviews with the Staff Development Coordinator and the Director of Nursing Services confirmed the absence of documentation for urinary output every shift, highlighting the facility's failure to ensure adequate monitoring and care for the resident's urinary catheter needs.
Failure to Implement Care Plan for Resident with Edema
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident with lower leg edema. The resident, who was admitted in April 2024 with Alzheimer's disease and hypertension, had a care plan initiated on April 8, 2024, which included the application of ACE wraps to both lower legs in the morning and their removal at bedtime. However, surveyor observations on May 20 and May 22, 2024, revealed that the resident was not wearing the ACE wraps as prescribed but was instead observed wearing non-skid socks. Interviews with the resident and staff members indicated a lack of awareness and implementation of the care plan. The resident stated that they had been wearing non-skid socks since admission and would wear the ACE wraps if provided. The primary nursing assistant and a registered nurse were both unaware of the care plan for the resident's bilateral leg edema. The Director of Nursing Services acknowledged that the care plan had not been implemented, confirming the deficiency in providing the necessary medical and nursing care as identified in the comprehensive assessment.
Failure to Follow Physician's Orders for Weekly Body Audits
Penalty
Summary
The facility failed to ensure that a resident received treatment and services in accordance with professional standards of practice by not following a physician's order for weekly body audits. The resident, who was admitted in April 2024, had diagnoses including Parkinson's disease and dementia. A physician's order dated April 17, 2024, required a body audit on admission and weekly by a licensed nurse on shower day, with documentation on the Body Audit Form. However, record reviews revealed that the weekly body audits were not completed and documented for four out of five opportunities between April 17, 2024, and May 21, 2024. During interviews, a registered nurse acknowledged the failure to complete and document the weekly body audits as per the physician's order. The Director of Nursing Services was also unable to provide evidence that the audits were completed and documented as required.
Failure to Act on Pharmacist's Recommendations for Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that irregularities identified by the Clinical Consultant Pharmacist during the monthly Medication Regimen Review (MRR) were addressed for two residents. For Resident ID #10, the pharmacist's Consultation Report recommended specific monitoring and documentation for the antipsychotic medication Seroquel, including monitoring for neuroleptic malignant syndrome, metabolic complications, and medication-specific side effects. However, the resident's medical record did not show evidence that these recommendations were reviewed or acted upon by the provider. Additionally, there was no documentation of ongoing monitoring for the specified conditions or behaviors. Similarly, for Resident ID #12, the pharmacist's Consultation Report included recommendations for monitoring and documentation related to the use of Haloperidol, another antipsychotic medication. The report suggested developing a care plan for mood or behavior, monitoring for neuroleptic malignant syndrome, metabolic complications, and medication-specific side effects. However, the resident's care plan lacked evidence of these actions, and the provider did not review or act upon the pharmacist's recommendations. Interviews with the Registered Nurse Practitioner and the Director of Nursing Services revealed uncertainty and lack of evidence regarding the review and implementation of the pharmacist's recommendations.
Medication Storage Deficiency
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with currently accepted professional principles, as observed by a surveyor in the medication storage room. During the inspection, it was found that a vial of tuberculin purified protein derivative was opened and undated, despite the manufacturer's instructions stating that the vial should be discarded after 30 days once opened. Additionally, there were issues with the storage of lorazepam intensol, a medication used to treat anxiety. Two unopened bottles of lorazepam intensol were found with expired manufacturer dates, and one opened bottle had a documented open date, but it was not discarded after the 90-day period as per the manufacturer's instructions. During an interview following the observation, Registered Nurse, Staff C, acknowledged the oversight regarding the undated tuberculin vial and the expired lorazepam bottles. Staff C was unable to provide an explanation for why the expired lorazepam bottles were not discarded. This indicates a lapse in following the facility's policy on the storage and expiration dating of medications and biologicals, which requires staff to record the date opened on medication containers and adhere to manufacturer guidelines for expiration dates.
Infection Control Deficiencies in Glucometer Disinfection and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, leading to potential infection risks. Specifically, a registered nurse, identified as Staff C, was observed using a blood glucose meter on a resident without properly disinfecting it according to the facility's policy. The policy required the use of specific EPA-approved disinfectants, but Staff C used an alcohol wipe instead. This practice was confirmed during an interview with Staff C, who admitted to using the glucometer for multiple residents without following the correct disinfection procedure. The Director of Nursing Services acknowledged the non-compliance with the disinfection policy but could not provide evidence of proper disinfection. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices, as required by their policy. During observations, several residents with devices such as a supra-pubic tube, gastrostomy tube, urinary catheter, and a peripherally inserted central catheter were not provided with the necessary EBP signage. Furthermore, staff members, including the Director of Nursing Services, were observed not wearing appropriate protective equipment, such as gowns and gloves, when interacting with these residents. The Director of Nursing Services was unable to explain the lack of adherence to the infection control policy for EBP during an interview.
Failure to Conduct Mandatory QAPI Training for Staff
Penalty
Summary
The facility failed to conduct mandatory training for all staff on the Quality Assurance and Performance Improvement (QAPI) program. A record review revealed that several staff members, including registered nurses and nursing assistants, did not complete the required QAPI training. Specifically, the records showed that an RN hired in 2022, another RN hired in 2020, and a third RN hired in 2017, along with nursing assistants hired in 2022, 2007, and 2000, had not received this training. Further review indicated that no current staff members had completed the mandatory QAPI training. During an interview, the Director of Nursing Services was unable to provide evidence that the facility had conducted the required training for all staff.
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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