Bayberry Commons
Inspection history, citations, penalties and survey trends for this long-term care facility in Pascoag, Rhode Island.
- Location
- 181 Davis Drive, Pascoag, Rhode Island 02859
- CMS Provider Number
- 415080
- Inspections on file
- 29
- Latest survey
- July 18, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Bayberry Commons during CMS and state inspections, most recent first.
Pharmacy consultant recommendations for medication regimen irregularities were not addressed by the attending physician for three residents, including those with back pain, Alzheimer's disease, and dementia. Recommendations included clarifying medication orders and adding appropriate diagnoses, but there was no evidence of physician review or action until surveyors brought the issues to the facility's attention.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with dementia and major depressive disorder did not receive an increased dose of sertraline as recommended by psychiatric services and approved by the provider, because the facility placed the order on hold pending POA consent. After an initial attempt to contact the POA, there was no further documented effort to obtain consent, and the provider was unaware the medication change had not been implemented.
A resident with a history of dysphagia had a change in physician's diet orders from aspiration precautions to a regular diet with thin liquids. Despite this, the TAR continued to be signed off as if aspiration precautions were still in place. Staff interviews confirmed that the outdated order was no longer active, but documentation was not updated accordingly, resulting in inaccurate medical records.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the plan was not prepared, reviewed, and revised by a team of health professionals as required.
A facility failed to notify a resident's physician of significant changes in the resident's condition, including lethargy and unresponsiveness, over several days. The resident, with a history of heart disease and reduced mobility, showed signs of deterioration, such as refusal of medication and meals, and was intermittently unarousable. Despite these changes, the physician was not notified until several days later, and vital signs were not documented. The resident was eventually hospitalized with respiratory failure, pneumonia, and a UTI, and later transferred to hospice care.
A resident with heart disease and other conditions did not receive several prescribed medications over three days. The facility's policy requires notifying the physician when medications are missed, but there was no evidence of such notification. The DNS acknowledged the lack of documentation, and the physician was unaware of the missed doses.
A facility failed to protect a resident from sexual abuse, as two residents with severe cognitive impairments were found engaging in sexual acts multiple times. Despite initial separation and 15-minute checks, the facility did not effectively monitor or intervene, leading to repeated incidents. Staff interviews confirmed the lack of consistent documentation and interventions, and the facility's leadership acknowledged the deficiency.
A facility failed to provide proper respiratory care for a resident with congestive heart failure and shortness of breath. Despite the resident's need for continuous oxygen therapy, there was no physician's order specifying the required oxygen flow and method. The deficiency was identified after the resident was hospitalized due to breathing difficulties, and staff interviews confirmed the lack of necessary documentation and orders.
A facility failed to maintain accurate medical records for a resident receiving oxygen therapy. Despite hospital records indicating the resident was on 3L of oxygen, the facility only had an order for 1L as needed. Progress notes showed varying oxygen levels, but these were not documented in the Medication Administration Record. Staff interviews revealed inconsistencies in documentation, with the DON unable to provide complete records.
A resident identified as a high fall risk was not provided with hip protectors, as required by their care plan, leading to a fall and a right femur fracture. The resident, who had severe cognitive impairment, was ambulating with staff when they tripped. An LPN noted the protectors were unavailable due to being soiled, and there was no documentation of the resident refusing them. The DON could not provide evidence that the protectors were offered or refused.
A resident with a history of falls was found to have two alarms engaged while in a wheelchair, which were not easily removable, indicating potential restraint use. The facility failed to provide evidence of assessments or ongoing evaluations for the alarms' necessity and effects. Staff interviews revealed a lack of awareness about any assessments, and the administration could not demonstrate that the alarms were the least restrictive intervention.
The facility failed to conduct comprehensive assessments for five residents and a Significant Change in Status Assessment (SCSA) for a resident admitted to hospice. Comprehensive assessments, which include the Minimum Data Set (MDS) and Care Area Assessment (CAA) process, were incomplete due to missing CAA documentation. Additionally, the required SCSA was not completed for a resident after admission to hospice services, as confirmed by the ADNS.
The facility failed to ensure accurate MDS assessments for several residents, leading to discrepancies in their medical records. A resident with repeated falls was inaccurately documented as using alarms less than daily, while another resident with nicotine dependence was incorrectly noted as not using tobacco. Additionally, a resident with a history of MRSA was still coded as having an active MDRO, and a resident with urine retention was inaccurately documented as having an indwelling catheter. The MDS Coordinator acknowledged these inaccuracies, and the administration could not provide evidence of accurate assessments.
A facility failed to maintain an infection prevention and control program for a resident with MRSA colonization. The resident's care plan aimed to prevent MRSA spread, but the facility did not conduct timely MRSA screenings or maintain required precautions. Observations confirmed the absence of necessary precautions, and staff could not provide evidence of an effective infection control program.
A resident on anticoagulant medication experienced an unwitnessed fall with a head strike and a subsequent headache. The NP was notified of the fall but not the headache, and gave a verbal order for neurological assessments and vital signs every shift for 72 hours. This order was not transcribed or executed, leading to a deficiency in care.
A resident with dysphagia was not provided food in a form suitable for their mechanical soft diet, receiving whole sausage links and bacon instead. Staff, including a nurse and cook, acknowledged the error, and the Assistant Director of Nursing Services confirmed the oversight.
Failure to Address Pharmacist-Identified Medication Irregularities
Penalty
Summary
The facility failed to ensure that drug regimen review (MRR) irregularities identified by the consultant pharmacist were addressed by the attending physician for three residents. For one resident with lower back pain and a spinal compression fracture, a pharmacy recommendation to specify the application area for a lidocaine patch was not acted upon. In another case, a resident with Alzheimer's disease had pharmacy recommendations regarding the administration of Miralax and clarification of vitamin D therapy, which were not addressed despite repeated notes from the consultant pharmacist. A third resident with dementia, vitamin D deficiency, and folate deficiency anemia had recommendations to add appropriate diagnoses for several medications, but these were also not addressed. Record review and staff interviews confirmed that there was no evidence the MRR irregularity recommendations were reviewed or acted upon by the physician for these residents, and the Director of Nursing Services was unable to provide documentation of follow-up. The facility's policy requires monitoring of consultant pharmacy services and timely response to identified irregularities, but this was not followed in these cases until the issues were identified by surveyors.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence or inadequacy of a comprehensive infection prevention and control program, but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Implement Psychiatric Medication Recommendation Due to Incomplete Consent Process
Penalty
Summary
A deficiency was identified when the facility failed to implement a psychiatric recommendation for a resident with dementia and major depressive disorder. The psychiatric provider recommended an increase in sertraline to 50 mg daily due to inappropriate behaviors, and this recommendation was approved by the resident's provider. However, the facility placed the new order on hold pending consent from the resident's Power of Attorney (POA). Documentation shows that a call was made to the POA to obtain consent, and a message was left, but there was no further evidence of additional attempts to contact the POA or obtain consent after that date. Interviews with staff confirmed that the facility's process requires obtaining and documenting consent from the resident representative before implementing changes to psychotropic medications. The LPN and DON both indicated that documentation of attempts to obtain consent should be present in the progress notes, but no such documentation was found after the initial attempt. The resident's provider was unaware that the medication increase had not been implemented and believed the resident was already receiving the higher dose.
Failure to Accurately Document and Update Medical Records for Diet Orders
Penalty
Summary
The facility failed to maintain accurate medical records and documentation in accordance with professional standards for a resident with a physician's order for aspiration precautions. The resident, who had diagnoses including Alzheimer's disease and a history of dysphagia, was readmitted with an order for aspiration precautions such as head of bed elevation, staff assistance during meals, oral care after eating, nectar thick fluids, and a puree diet. Subsequently, a new physician's order was issued for a regular house diet with thin liquids. Despite this change, the Treatment Administration Record (TAR) continued to reflect that aspiration precautions were being implemented and signed off as completed three times daily, even after the new diet order was in place. Surveyor observation revealed the resident eating alone with thin liquids and a regular diet, contrary to the previous aspiration precautions. Interviews with staff confirmed that the order for aspiration precautions was no longer active, yet documentation on the TAR indicated otherwise. One LPN acknowledged signing off on the aspiration precautions without verifying the current diet order, and the Director of Nursing Services stated that staff are expected to document accurately. This discrepancy between actual care provided and documentation led to the deficiency.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to immediately consult with the resident's physician and notify them when there was a significant change in the resident's condition. This deficiency was identified for a resident who experienced a change in condition, including lethargy and unresponsiveness, over several days. The resident, admitted with diagnoses such as heart disease and reduced mobility, showed signs of deterioration, including refusal of medication and meals, and was intermittently unarousable. Despite these changes, there was no evidence that the physician was notified until several days later. The resident's condition continued to decline, with progress notes indicating poor fluid intake, difficulty with ambulation, and unresponsiveness to verbal stimuli. Vital signs were not documented for several days following the change in condition. The resident was eventually found to have fallen, with a significant drop in oxygen saturation, and was transferred to the hospital where they were diagnosed with hypercapnic respiratory failure, pneumonia, and a urinary tract infection. The facility's records failed to show that the physician was informed of the missed medications or the resident's deteriorating condition in a timely manner. Interviews with staff revealed that there was an expectation for the physician to be notified of such changes, but this did not occur. The Director of Nursing Services acknowledged the lack of appropriate documentation and physician notification. The resident was later transferred to hospice care following the hospital admission and passed away shortly thereafter. The facility did not have a specific policy for notifying physicians of a change in condition, contributing to the deficiency.
Failure to Notify Physician of Missed Medications
Penalty
Summary
The facility failed to meet professional standards of quality by not following physician's orders for a resident who refused medications. The resident, admitted in November 2024 with diagnoses including heart disease, acute pulmonary edema, and reduced mobility, did not receive several prescribed medications on specific dates in February 2025. These medications included Aspirin, Furosemide, Gentle Iron, Metoprolol Succinate Extended Release, Polyethylene Glycol, Warfarin, Melatonin, Simvastatin, Trazodone, and Zyprexa. The facility's Medication Administration Record (MAR) showed these medications were not administered on February 2nd, 3rd, and 4th, 2025. The facility's policy requires physician notification when a medication is not administered due to resident refusal or other reasons. However, the record review failed to show evidence that the physician was notified of the missed medications. Interviews with the Director of Nursing Services (DNS) and the resident's physician confirmed that the physician was not informed within the expected timeframe. The DNS acknowledged the lack of appropriate documentation in the resident's medical record, and the physician indicated he was not aware of the missed medications.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by multiple incidents involving two residents with severe cognitive impairments. Resident ID #1, who has dementia and a BIMS score indicating severe cognitive impairment, was found in compromising situations with Resident ID #2, who also has dementia and was unable to complete a BIMS assessment due to cognitive limitations. Both residents were observed engaging in sexual acts, despite their inability to consent due to their cognitive conditions. The incidents occurred on a secured unit, where staff initially separated the residents after observing inappropriate behavior. However, the residents were later found in similar situations multiple times, indicating a lack of effective monitoring and intervention. The facility's policy on abuse prohibition requires an evaluation of a resident's capacity to consent to sexual activity, which was not adequately addressed in this case. The 15-minute checks implemented after the initial incident were not consistently documented, and no new interventions were put in place after subsequent incidents. Staff interviews revealed that the residents were separated after each incident, but the measures taken were insufficient to prevent further occurrences. The facility's failure to document the 15-minute checks and implement effective interventions contributed to the ongoing risk of abuse. The Director of Nursing Services and the Administrator acknowledged the repeated incidents and the lack of evidence that the facility kept Resident ID #1 free from sexual abuse.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident who required oxygen therapy. The resident, who had diagnoses including congestive heart failure and shortness of breath, was readmitted to the facility in June 2024. Despite the resident's need for continuous oxygen therapy, the facility did not have a physician's order for continuous oxygen, which is required to specify the liter flow and method of administration. The resident was documented as receiving oxygen on several occasions, but there was no evidence of a physician's order for continuous oxygen therapy. The deficiency was identified following a community-reported complaint that the resident was transported to the hospital due to breathing difficulties. Interviews with facility staff, including a Licensed Practical Nurse, a Registered Nurse, and the Director of Nursing Services, confirmed the absence of a physician's order for continuous oxygen. The Director of Nursing Services acknowledged the need for such an order and the requirement to document the resident's oxygen saturation level every shift, but could not explain why the order was not in place.
Failure to Maintain Accurate Oxygen Therapy Records
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with professional standards for a resident receiving oxygen therapy. The resident, who was readmitted to the facility with diagnoses including congestive heart failure and shortness of breath, was documented in hospital records as being on 3 liters of oxygen at baseline. However, the facility's records only showed a physician's order for oxygen at 1 liter via nasal cannula as needed, with no evidence of an order for continuous oxygen therapy. Progress notes indicated the resident was receiving varying levels of oxygen on multiple dates, but these were not documented in the Medication Administration Record. Interviews with staff revealed inconsistencies in the documentation of the resident's oxygen therapy. A Licensed Practical Nurse confirmed that the resident utilized oxygen continuously, receiving between 1-3 liters. The Director of Nursing Services acknowledged the expectation for staff to document oxygen administration and the resident's oxygen saturation level every shift, but was unable to provide evidence of complete and accurate records. This lack of documentation and adherence to professional standards led to the deficiency finding.
Failure to Provide Hip Protectors Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that a resident, identified as a high fall risk, was provided with hip protectors as an intervention to prevent accidents. The resident, who had severe cognitive impairment and a history of falls, was ambulating with staff assistance when they tripped and fell, resulting in a right femur fracture. A physician's order was in place to encourage the use of hip protectors at all times, except during personal care, but the resident was not wearing them at the time of the fall. The incident report and staff interviews revealed that the hip protectors were marked as unavailable by an LPN on the shift when the fall occurred. The LPN could not recall if the resident was wearing the protectors and acknowledged that they were not provided due to being soiled. The Director of Nursing Services was unable to provide evidence that the hip protectors were offered or refused by the resident, and there was no documentation in the progress notes indicating that the resident declined to wear them. This oversight led to the resident sustaining a broken hip.
Failure to Assess and Document Use of Alarms as Restraints
Penalty
Summary
The facility failed to ensure that residents are free from physical restraints that are not required to treat medical symptoms, specifically in the case of a resident who was using two alarms as a fall intervention. The resident, who was admitted in September 2021 with diagnoses including difficulty walking and repeated falls, was found to have two alarms engaged while sitting in a wheelchair. These alarms were intended to prevent the resident from getting out of the chair, and the resident expressed dislike for them. The alarms were not easily removable by the resident, indicating a potential restraint situation. The facility did not provide evidence of an assessment for the use of these alarms or any ongoing evaluation of their necessity and potential adverse effects. Interviews with staff revealed a lack of awareness regarding any assessments performed for the alarms' use. The Administrator and Assistant Director of Nursing acknowledged the use of the alarms but could not demonstrate that they did not restrict the resident's movement or that they were the least restrictive intervention. This lack of documentation and assessment led to the deficiency noted by the surveyors.
Failure to Conduct Comprehensive and Significant Change Assessments
Penalty
Summary
The facility failed to conduct comprehensive assessments using the Resident Assessment Instrument (RAI) for five out of six residents reviewed. These assessments are required to include both the Minimum Data Set (MDS) and the Care Area Assessment (CAA) process, as well as care planning. The MDS is a preliminary assessment that identifies potential resident problems, while the CAA process provides further assessment of triggered areas. For residents with IDs 7, 25, 39, 53, and 89, the facility did not complete the necessary CAA documentation, which should include information on complicating factors, risks, and any referrals for the care areas. The Minimum Data Set Coordinator acknowledged the absence of CAA notes for these residents during a surveyor interview. Additionally, the facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who was admitted to hospice services, indicating a significant change in health status. According to the MDS 3.0 Resident Assessment Instrument Manual, an SCSA is required when a resident elects the hospice benefit. The record review for this resident, identified as Resident ID #50, did not reveal evidence of a completed SCSA after the resident's admission to hospice services. The Assistant Director of Nursing Services (ADNS) confirmed during an interview that a significant change assessment should have been completed. These deficiencies highlight the facility's failure to adhere to the required assessment protocols, which are crucial for identifying and addressing the needs of residents. The lack of comprehensive assessments and significant change assessments can impede the development of individualized care plans aimed at promoting residents' highest practicable level of functioning.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure accurate assessments for several residents, leading to discrepancies in their medical records. Resident ID #8, who was readmitted with a diagnosis of repeated falls, was inaccurately assessed in the Minimum Data Set (MDS) as using bed and chair alarms less than daily, despite a physician's order indicating daily use. Similarly, Resident ID #19, diagnosed with nicotine dependence, was incorrectly documented as not using tobacco in the MDS, although the care plan indicated the resident was an independent smoker. Further inaccuracies were found with Resident ID #25, who was admitted with a diagnosis of MRSA. Despite two consecutive negative MRSA screenings, the resident was still coded as having an active MDRO in the MDS. Additionally, Resident ID #56, admitted with urine retention, was inaccurately documented as having an indwelling catheter in two MDS assessments, even though the catheter had been removed. The MDS Coordinator acknowledged these inaccuracies, and the facility's administration could not provide evidence of accurate MDS assessments for these residents.
Failure to Implement 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, specifically concerning Multi-drug Resistant Organisms (MDRO). The deficiency was identified for one resident who was readmitted to the facility with a diagnosis of MRSA colonization. The facility's policy required Enhanced Barrier Precautions for residents with MDRO colonization, which includes the use of gowns and gloves during high-contact care activities. However, the facility did not adhere to these precautions for the resident in question. The resident's care plan indicated a goal to prevent the spread of MRSA, yet the facility did not conduct timely MRSA screenings as per their policy. The resident tested positive for MRSA in the nares in 2021, and a subsequent MRSA screen was delayed until 2024, which resulted negative. Despite this, there was no evidence of two consecutive negative MRSA cultures before removing the resident from Contact or Enhanced Barrier Precautions. Observations during the survey confirmed that the resident was not on the required precautions, and the facility staff could not provide evidence of maintaining an effective infection prevention and control program.
Failure to Transcribe and Execute Verbal Orders for Post-Fall Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The resident, who was on an anticoagulant medication, experienced an unwitnessed fall with a head strike and subsequently developed a headache. Although the Nurse Practitioner was notified of the fall and aware of the resident's anticoagulant use, she was not informed about the resident's headache. She had given a verbal order for neurological assessments and vital signs to be completed every shift for 72 hours, but this order was not transcribed into the resident's record. Further review revealed that there was no evidence that the neurological assessments and vital signs were completed as per the Nurse Practitioner's verbal order. The Assistant Director of Nursing confirmed the lack of documentation and stated that residents with a head strike while on an anticoagulant should be sent to the emergency room for evaluation. This oversight in communication and documentation led to a deficiency in the care provided to the resident.
Failure to Provide Appropriate Mechanical Soft Diet
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of a resident on a mechanical soft diet. The resident, who was admitted with a diagnosis of dysphagia, experienced difficulty swallowing during a meal, which led to a diet downgrade to mechanical soft as per a physician's order. Despite this, the resident was served inappropriate food items, such as whole sausage links and bacon, which are not suitable for a mechanical soft diet. Surveyor observations and interviews revealed that the resident was served whole sausage links and bacon on separate occasions, which the resident found difficult to eat. Staff members, including a registered nurse and a cook, acknowledged that these food items were not appropriate for the resident's dietary needs. The Assistant Director of Nursing Services also confirmed that the resident should not have received these items and was unable to provide evidence that the food was prepared according to the resident's individual needs.
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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