Berkshire Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Providence, Rhode Island.
- Location
- 455 Douglas Avenue, Providence, Rhode Island 02908
- CMS Provider Number
- 415119
- Inspections on file
- 56
- Latest survey
- September 4, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Berkshire Place during CMS and state inspections, most recent first.
A resident with dementia and anxiety disorder, who was cognitively intact, threatened to physically harm another resident and was sent to the ER for evaluation. The DON acknowledged that this incident, which met the criteria for abuse reporting, was not reported to RIDOH as required by state law and facility policy.
Surveyors found that medications, including Trelegy Ellipta inhalers, Morphine Sulfate, and Lorazepam Intensol, were opened and not dated, and that Lorazepam was not refrigerated as required. Staff acknowledged these lapses in medication storage and labeling during interviews.
A resident with schizophrenia and moderate cognitive impairment, who was dependent on staff for supervision, successfully eloped from the facility after repeatedly expressing a desire to leave. Despite prior documentation of elopement risk and a physician order restricting leave, the facility did not reassess the resident's risk or update the care plan after the incident, and failed to complete required assessments or documentation.
A facility failed to notify a resident and their representative of a transfer or discharge, including the reasons for the move, in writing and in a language and manner they understand. The resident, with severe cognitive impairment and diagnoses of violent behaviors and dementia, was transferred to the hospital following an alleged interaction and subsequently discharged. The facility could not provide evidence of the required notification during a surveyor interview.
A facility failed to provide a resident or their representative with written notification of the bed-hold policy during a hospital transfer. The resident, with severe cognitive impairment and a history of violent behaviors, was transferred following an interaction with another resident. The facility's Administrator and DON could not provide evidence of the required notification.
A facility failed to allow a resident to return after hospitalization, violating bed-hold policy. The resident, admitted since 2019 with dementia and violent behaviors, was sent to the hospital for evaluation after an incident. Diagnosed with COVID-19 and a UTI, the resident was discharged without a 30-day notice. The Administrator and DON confirmed the decision not to allow the resident's return, despite the lack of documentation supporting this action.
The facility was found deficient in food safety standards as hot food items were served below the required temperature, and there was no evidence of reheating to meet policy standards. Additionally, a dietary aide was observed handling equipment in the kitchen without a hair restraint, contrary to facility policy. These issues were identified during a survey following a complaint about food temperatures and staff not wearing hairnets.
The facility failed to provide food and drinks at an appetizing temperature for several residents. A community complaint highlighted that hot food items were served cold. Residents reported ongoing issues with cold food, leading some to source meals externally or reheat them personally. A test tray confirmed that food temperatures were below the facility's policy requirements, with staff acknowledging the failure to maintain appropriate temperatures.
A resident with moderately impaired cognition allegedly touched another resident with severely impaired cognition inappropriately in a sunroom. The incident was witnessed by a cognitively intact resident who intervened and reported it to staff. The police were involved, and the resident was arrested for second-degree sexual assault.
Multiple residents experienced significant medication errors due to transcription mistakes and failure to follow physician orders. A resident with hypertension received Lasix despite an order to hold it, while another with gastric ulcer and diabetes received incorrect dosages of metronidazole and missed metformin doses. A resident with seizures missed doses of Valproic Acid, and a resident with heart failure received an incorrect total dose of Lasix. Staff acknowledged these errors during surveyor interviews.
A facility failed to create a comprehensive care plan for a resident identified as a smoker, despite assessments confirming nicotine dependence. The DON acknowledged the oversight during an interview.
A resident with severe morbid obesity and muscle weakness, dependent on staff for bathing, did not receive scheduled showers as ordered. Despite a care plan and physician's order for biweekly showers, staff interviews and surveyor observations revealed the resident had not been showered since May. The primary NA admitted to not providing showers, and facility management could not provide evidence of compliance with the care plan.
A facility failed to document the administration of oxygen for a resident with lung cancer and pneumonia, as required by their policy and professional standards. Despite physician orders specifying oxygen flow rates and conditions, records did not consistently reflect the amount of oxygen administered, even when the resident was observed on oxygen. The resident's physician expected proper documentation, highlighting a deficiency in respiratory care practices.
The facility failed to follow physician's orders for two residents. One resident did not receive scheduled laboratory tests for Valproic Acid levels, and another resident did not have daily weights recorded or a psychiatric consult completed. The DNS could not provide evidence of these actions during the surveyor interviews.
The facility failed to maintain accurate medical records for two residents. One resident did not receive a shower and wound treatment as documented, and another resident did not have a psychiatric evaluation as ordered. Staff interviews confirmed the inaccuracies in documentation.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported to the Rhode Island Department of Health (RIDOH) as required by state law and facility policy. Specifically, a resident with diagnoses including dementia and anxiety disorder, who was cognitively intact according to a recent assessment, threatened to physically harm another resident. This incident was documented in a progress note, and the resident was subsequently sent to the emergency room for evaluation and admitted. Despite the facility's policy requiring immediate reporting of suspected abuse to the Director of Nursing and RIDOH, the Director of Nursing acknowledged during a surveyor interview that the incident was not reported to RIDOH. The failure to report the allegation of abuse in a timely manner constituted noncompliance with both state regulations and the facility's own procedures.
Failure to Properly Store and Label Medications
Penalty
Summary
Surveyor observations revealed that drugs and biologicals were not stored and labeled according to professional standards in two of four medication carts inspected. Specifically, two Trelegy Ellipta inhalers were found opened and undated, despite manufacturer instructions requiring disposal six weeks after opening. Additionally, Morphine Sulfate and Lorazepam Intensol oral suspension were found opened and undated, with the Lorazepam not stored in the required refrigerated conditions. The pharmacy label and manufacturer instructions for these medications specify discard dates and storage requirements that were not followed. Staff present during these observations, including a Certified Medication Technician, an LPN, and an RN, acknowledged the deficiencies when interviewed by surveyors. The Director of Nursing Services also confirmed that medications should be dated when opened and that Lorazepam should be refrigerated. These findings were consistent with a community complaint alleging improper medication storage and administration.
Failure to Assess and Intervene After Resident Elopement
Penalty
Summary
A resident with a diagnosis of schizophrenia and moderately impaired cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 9 out of 15, was admitted to the facility and required supervision for ambulation and dressing. Despite a physician order prohibiting the resident from taking a leave of absence, and documentation that the resident was an elopement risk and required supervision for smoking, the facility failed to reassess the resident's elopement risk after multiple documented behaviors indicating a desire to leave, including repeated requests to go home and expressing a strong desire to return home. The resident ultimately left the facility unsupervised and traveled to a previous residence, with the facility only learning of the elopement after being contacted by the other location. Following the resident's return, the facility did not perform an elopement assessment or develop a care plan with interventions to minimize further risk, as required by its own policy. Progress notes and staff interviews confirmed that no elopement evaluation or AMA discharge documentation was completed after the incident, and the Director of Nursing and Administrator acknowledged these omissions. The facility's failure to identify and address the resident's increased risk for elopement, and to implement appropriate interventions after the event, resulted in a deficiency related to inadequate supervision and accident prevention.
Failure to Notify Resident and Representative of Transfer or Discharge
Penalty
Summary
The facility failed to notify a resident and their representative of a transfer or discharge, including the reasons for the move, in writing and in a language and manner they understand. This deficiency was identified for a resident who was transferred to the hospital and subsequently discharged from the facility. The resident, who had been admitted in July 2019 with diagnoses of violent behaviors and dementia, was involved in an alleged resident-to-resident interaction that led to their transfer to the emergency room on January 14, 2025. The record review did not reveal any evidence that the facility provided the required notification to the resident or their representative. During an interview with the Administrator and the Director of Nursing, they were unable to provide documentation that the necessary notifications were made. The resident's severe cognitive impairment, as indicated by a Quarterly Minimum Data Set Assessment, further underscores the importance of proper communication with their representative.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification to a resident or their representative regarding the bed-hold policy during a transfer to the hospital. The deficiency was identified through a record review and staff interviews, which revealed that the facility did not provide the required written notice specifying the duration of the bed-hold policy at the time of the resident's transfer. This oversight was noted for a resident who was transferred to the emergency room following an alleged interaction with another resident. The resident, who was admitted to the facility in July 2019 with diagnoses of violent behaviors and dementia, was documented as having severe cognitive impairment. The complaint, submitted to the Rhode Island Department of Health, alleged that the resident was not allowed to return to the facility and did not receive a 30-day notice as required. During an interview, the facility's Administrator and Director of Nursing were unable to provide evidence of the required written notification to the resident or their representative regarding the bed-hold policy.
Facility Fails to Allow Resident Return Post-Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after a hospitalization, violating the bed-hold policy. The resident, who had been living in the facility since July 2019, was transferred to the hospital for a psychological evaluation following an alleged interaction with another resident. The hospital diagnosed the resident with COVID-19 and a urinary tract infection, which can cause agitation in the elderly. Despite these circumstances, the facility discharged the resident on the same day as the hospital transfer, without providing the required 30-day notice. Surveyor observations confirmed that the resident's room was vacant following the transfer. During interviews, the Administrator and the Director of Nurses admitted that they decided not to allow the resident to return to the facility. This decision was made despite the absence of documentation supporting the resident's discharge or any evidence that the resident was given the opportunity to return after hospitalization, as required by regulations.
Deficiencies in Food Safety and Hair Restraint Compliance
Penalty
Summary
The facility failed to adhere to professional standards of food service safety during meal preparation, storage, and distribution. During a surveyor observation, it was noted that the temperatures of hot food items on the steam table were below the required holding temperature of 135 degrees Fahrenheit. Specifically, mashed potatoes were at 129.2 F, chicken at 128.3 F, and burger patties at 125.4 F. The facility's policy mandates that if food is below 135 F, it should be reheated to at least 165 F for a minimum of 15 seconds before serving. However, there was no evidence that these food items were reheated to meet the policy requirements. The Food Service Director acknowledged that the food should have been reheated according to the facility's policy. Additionally, the facility did not comply with the Rhode Island Food Code regarding the use of hair restraints in the kitchen. During an observation, a dietary aide was seen handling equipment in the main kitchen without wearing a hair restraint, which is against the facility's policy. The Food Service Director confirmed that all staff are expected to wear hair restraints while working in the kitchen. These deficiencies were identified during a survey following a community-reported complaint about food being served at unappetizing temperatures and staff not wearing hairnets.
Failure to Maintain Appropriate Food Temperatures
Penalty
Summary
The facility failed to provide food and drinks that are palatable, attractive, and at an appetizing temperature for four out of five residents reviewed. A community complaint was submitted to the Rhode Island Department of Health, alleging that hot food items were being served cold and at an unappetizing temperature. The facility's policy requires hot foods on room trays to be at 120°F or greater to promote palatability. However, surveyor interviews with residents revealed ongoing issues with cold food. Resident ID #2, admitted in September 2021 with type II diabetes mellitus, reported that hot food items have always been cold since admission. Resident ID #3, admitted in October 2024 with hypertension, stated that the food served within the last week was cold and not palatable, leading to sourcing meals from outside the facility. Resident ID #4, readmitted in August 2024 with depression, mentioned having to microwave food daily due to it being served cold. Resident ID #5, admitted in September 2024 with gastro-esophageal reflux disease, refused to eat breakfast because it was not hot and had to heat the food personally. A test tray ordered by the Unit Manager, Staff A, showed that the food temperatures were below the facility's policy requirements. The mashed potatoes were at 112.7°F, chicken at 106.1°F, and vegetables at 117.8°F. Staff A acknowledged that the food failed to hold the temperature from the steamer and expected temperatures closer to 135°F. The Food Service Director also expected the food to be at least 120°F or higher, per the facility policy. These findings indicate a failure to maintain appropriate food temperatures, leading to dissatisfaction among residents and non-compliance with the facility's policy on food service temperatures.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, as evidenced by an incident involving two residents. Resident ID #1 reported that Resident ID #2 entered their room and joined them in bed without consent. Further allegations were made that Resident ID #2 sat on Resident ID #1's face while fully clothed, leading Resident ID #1 to retaliate by touching Resident ID #2's genitals. Resident ID #1 was admitted with mild neurocognitive disorder and had a BIMS score indicating moderately impaired cognition. Resident ID #2, with a history of dementia and schizophrenia, had a BIMS score indicating severely impaired cognition, making it difficult for surveyors to interview them. The incident was witnessed by another resident, Resident ID #4, who reported seeing Resident ID #1 touch Resident ID #2's thigh and move their hand towards the upper thigh in the sunroom. Resident ID #4, who had no cognitive impairments, intervened and reported the incident to the facility staff. The police were involved, and Resident ID #1 was arrested for second-degree sexual assault. The facility's failure to prevent this incident and protect the residents from abuse constitutes a deficiency in their care standards.
Medication Errors Affect Multiple Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting four out of nine residents reviewed. Resident ID #111, who was admitted with hypertension and acute kidney failure, received Lasix despite an order to hold the medication for three days due to lab results. The medication was administered on three consecutive days in error. Resident ID #136, with a history of gastric ulcer and diabetes mellitus, received an incorrect dosage and frequency of metronidazole due to a transcription error, and missed 34 doses of metformin because the order was not transcribed. The errors were acknowledged by the staff involved during surveyor interviews. Resident ID #162, admitted with seizures, did not receive Valproic Acid on two occasions, and the provider was not notified of the missed doses. Staff acknowledged the oversight during interviews. Resident ID #186, with abnormal blood chemistry and heart failure, received an incorrect total dose of Lasix due to a failure to hold the 20 mg dose as ordered and an error in administering both 20 mg and 40 mg doses on the same day. The staff involved confirmed the administration errors during surveyor interviews, and the Director of Nursing Services was unable to provide evidence that the Lasix order was followed correctly.
Failure to Develop Comprehensive Smoking Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident identified as a smoker. The resident was admitted to the facility in May 2024 with a diagnosis that included nicotine dependence. A smoking assessment was completed upon both admission and re-admission, indicating the resident is a smoker. However, the facility did not create a comprehensive care plan for smoking as required by their policy. During an interview, the Director of Nursing Services acknowledged the resident's smoking status and the absence of a comprehensive care plan addressing this issue.
Failure to Provide Scheduled Showers to Dependent Resident
Penalty
Summary
The facility failed to provide necessary services to a resident who was unable to carry out activities of daily living, specifically regarding scheduled showers. The resident, admitted in June 2023 with severe morbid obesity and generalized muscle weakness, was dependent on staff assistance for bathing and showering. A care plan dated January 2024 confirmed the resident's dependency on staff for self-care and mobility, including showers. A physician's order from July 2024 specified biweekly showers on Mondays and Thursdays during the day shift. However, surveyor observations on July 24 and 25, 2024, noted a strong odor of urine in the resident's room, and the resident reported not having received a shower since moving to the unit in May 2024. Interviews with staff revealed further deficiencies in care. The resident's primary Nursing Assistant (NA), Staff B, admitted to not providing the resident with a shower since May 2024, despite being assigned to the resident on specific dates when showers were ordered. Staff B also acknowledged that the shower chair was not broken, contradicting the reason given to the resident for not receiving showers. Additionally, the unit manager, an LPN, and the Director of Nursing Services were unable to provide evidence that the resident received showers as ordered, indicating a systemic failure in adhering to the care plan and physician's orders for the resident's hygiene needs.
Failure to Document Oxygen Administration
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident with a history of lung cancer, shortness of breath, and pneumonia. The deficiency was identified through surveyor observation, record review, and staff interviews. According to the facility's policy and the Lippincott Manual of Nursing Practice, documentation of oxygen administration should include the date, time, amount, and method of administration, as well as the resident's condition before and after therapy. However, the facility's records did not consistently document the amount of oxygen administered to the resident on several occasions, despite the resident being observed on oxygen during surveyor visits. The resident had a physician's order for oxygen administration, specifying a flow rate of 2-4 liters via nasal cannula, with instructions to titrate as needed to maintain pulse oximetry levels above 88% on room air. Despite these orders, the facility's Treatment Administration Record for July 2024 failed to document the administration of oxygen on specific dates, as required by the facility's policy. During an interview, the resident's physician expressed the expectation that staff should document the date, time, and amount of oxygen administered each time it is given. This lack of documentation represents a failure to adhere to the facility's policy and professional standards of practice for respiratory care.
Failure to Follow Physician's Orders for Laboratory Tests and Consults
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice by not following physician's orders for two residents. Resident ID #162, who was admitted with a seizure disorder, had a physician's order for Valproic Acid and required bloodwork, including a comprehensive metabolic panel (CMP) and Valproic Acid level, every six months starting on 6/12/2024. However, the laboratory results for these tests were not obtained as ordered, and the Director of Nursing Services (DNS) could not provide evidence of the completed laboratory work during the surveyor interview. Resident ID #241, admitted with cirrhosis of the liver, ascites, and a history of depression, had a physician's order for daily weights and a psychiatric consult. The resident's weights were not recorded on two specific dates, and there was no evidence that the psychiatric consult was completed. The DNS acknowledged the failure to obtain daily weights and could not provide evidence of the psychiatric evaluation during the surveyor interview. The resident's physician expressed the need for a psychiatric evaluation before starting any medications.
Inaccurate Medical Record Documentation for Resident Care
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with professional standards for two residents. For Resident ID #111, discrepancies were found in the documentation of shower schedules and wound treatment. The resident was admitted with diagnoses including morbid obesity and generalized muscle weakness. The physician's orders specified a weekly shower schedule and the application of a skin protectant cream to a wound on the left posterior thigh. However, the Nursing Assistant assignment log showed a different shower schedule, and the Treatment Administration Record inaccurately indicated that the resident received a shower and wound treatment on a specific date. Interviews with the Nursing Assistant and Registered Nurse involved confirmed that the documented care was not provided. For Resident ID #241, the facility failed to provide evidence of a psychiatric evaluation as ordered. The resident, admitted with cirrhosis of the liver, ascites, and a history of depression, had a physician's order for a psychiatric consultation. Although a form indicated that the psychiatric provider signed off on completing the consult, there was no evidence that the evaluation occurred. An interview with the Director of Nursing Services revealed the absence of documentation to support that the psychiatric evaluation was conducted, and subsequent communication with the psychiatric provider confirmed that the evaluation was not completed.
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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