Brentwood Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Warwick, Rhode Island.
- Location
- 4000 Post Road, Warwick, Rhode Island 02886
- CMS Provider Number
- 415061
- Inspections on file
- 27
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Brentwood Health Center during CMS and state inspections, most recent first.
A resident with chronic respiratory failure and hypoxia was readmitted with physician orders for BiPAP therapy during naps and nightly. The facility did not provide the BiPAP as ordered for several days, as confirmed by treatment records and staff interviews, resulting in a worsening of the resident's respiratory condition.
Four residents with chronic pain and other serious conditions did not have their pain management care plan interventions implemented or documented, despite care plans specifying actions such as administering pain medication and monitoring effectiveness. Staff confirmed that pain was not documented as required, and only verbal inquiries were made, resulting in a lack of evidence that residents' pain was properly managed.
A resident with multiple serious diagnoses and under hospice care did not receive PRN morphine for pain as ordered, despite repeated complaints and requests, with staff confirming no additional doses were given before hospital transfer. Additionally, an air mattress was in use for the resident without a physician's order or documented settings, as confirmed by staff and record review.
The facility failed to document physician-ordered weekly skin evaluations for two residents. One resident, with malnutrition and fractures, had evaluations signed off without evidence of completion. Another resident, with dementia and syncope, also had evaluations signed off without documentation. The DON could not provide evidence of completed assessments.
The facility did not ensure that NAs Staff A and B had the necessary competencies for safe patient handling with mechanical lifts. Despite the facility's requirement for training during orientation and annually, there was no evidence that these competencies were completed for Staff A and B before they began resident care. This was confirmed during an interview with the Regional Nurse.
The facility did not complete annual performance reviews for NAs, as required. A review of personnel files showed no evidence of evaluations for five NAs hired between 2005 and 2023. The DON could not provide documentation of evaluations within the last year.
The facility did not offer bedtime snacks to residents, resulting in more than 14 hours between supper and breakfast, as reported by several residents during a council meeting. The Administrator confirmed the meal schedule and could not provide evidence of snack offerings.
The facility failed to meet food safety and sanitation standards, with unlabeled and expired food items found in the kitchen and nourishment areas. Food packaging was compromised, and the dishwasher did not reach the required sanitization temperature. The FSD was observed serving food without a beard restraint, and there was no certified food safety manager present during certain hours due to an expired certification.
The facility failed to implement and maintain an effective, comprehensive, data-driven QAPI program. Although QAPI plans were created for identified concerns, there was no evidence of their implementation or maintenance, including tracking and measuring performance, and establishing goals and thresholds. The facility Administrator could not provide evidence of an effective QAPI program focusing on care outcomes and quality of life.
A long-term care facility was found deficient in infection control practices, including improper hand hygiene and PPE use by staff, inadequate precautions for MDROs, and improper handling of soiled linens. A Nursing Assistant failed to use gloves and perform hand hygiene, a housekeeper did not wear PPE in a Contact Precaution room, and the laundry process lacked proper gown use and lint filter maintenance.
The facility failed to provide appropriate dialysis care for two residents with end-stage renal disease. One resident lacked documentation for AVF dressing care and inconsistent thrill and bruit assessments, while another resident removed their own AVF dressing without staff orders. Staff interviews confirmed the absence of necessary orders and incomplete documentation.
The facility failed to properly store and label medications in three medication carts. An Arnuity Ellipta inhaler and an Insulin Glargine Pen were found opened and undated, contrary to manufacturer instructions. An unopened Insulin Glargine vial was improperly stored outside refrigeration, and a Breo Ellipta inhaler was also opened and undated. The Regional Clinical Nurse could not explain the improper storage and acknowledged the need for dating medications upon opening.
Two residents experienced significant medication errors. A resident with diabetes did not receive their Tresiba Insulin due to an LPN's inability to locate it, with no documentation of provider notification. Another resident with end-stage renal disease missed several doses of Sevelamer Carbonate due to being unavailable or at dialysis, with no evidence of administration as ordered.
A Spanish-speaking resident in a LTC facility experienced distress due to communication barriers with staff who did not speak Spanish. Despite having intact cognition, the resident struggled to convey personal needs, leading to inadequate care and feelings of sadness. Staff relied on gestures and other Spanish-speaking employees, but these were insufficient. The facility lacked effective communication tools, and the social worker and DON failed to ensure proper use of translation services.
The facility failed to notify the State LTC Ombudsman of the discharges of two residents. One resident, admitted with hemiplegia and hemiparesis, was discharged to the hospital, while another, admitted with hyponatremia, was discharged home with services. Record reviews and staff interviews confirmed the lack of notification.
A resident did not receive medication administration verification by a second nurse as ordered, according to a physician's directive. The MAR for May and June showed no evidence of compliance, and interviews with LPNs confirmed the oversight. The DON could not provide evidence of the required verification.
Failure to Provide Timely BiPAP Therapy for Resident with Chronic Respiratory Failure
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards of practice for a resident requiring a BiPAP device. The resident, who had a diagnosis of chronic respiratory failure with hypoxia, was readmitted to the facility with physician discharge instructions and orders specifying the need for BiPAP use during naps and nightly. However, review of the treatment administration record showed no evidence that the BiPAP was administered for several days following readmission. Progress notes indicated that the resident's condition worsened, with symptoms such as shortness of breath and cough, due to the lack of BiPAP therapy. Nursing staff and nurse practitioners confirmed that the BiPAP machine was not available or adjusted for use until several days after the resident's return, and the Director of Nursing Services acknowledged that the device was not provided as ordered within the expected timeframe. The deficiency was identified through record review and staff interviews, which confirmed the delay in providing the prescribed respiratory care.
Failure to Implement and Document Pain Management Interventions
Penalty
Summary
The facility failed to implement comprehensive, person-centered care plans for four residents regarding pain medication administration. For each resident, although care plans were developed with specific interventions such as administering pain medications, monitoring and recording pain levels, and documenting effectiveness and side effects, there was no evidence in the medical records that these interventions were carried out. The residents involved had various diagnoses, including chronic pain, pressure ulcers, adult failure to thrive, and depression, with cognitive statuses ranging from intact to severely impaired. Despite care plans being in place and revised as needed, the required documentation and follow-through on pain management interventions were absent. Staff interviews confirmed these deficiencies, with a registered nurse acknowledging that pain was not documented as outlined in the care plans and that staff only verbally inquired about pain. The Assistant Director of Nursing stated that staff were expected to follow care plans, but the records did not reflect implementation of the pain management interventions. These findings were based on record reviews and staff interviews, as well as a community complaint regarding a resident not receiving pain medication despite reporting significant pain.
Failure to Follow Physician's Orders for Pain Management and Air Mattress Use
Penalty
Summary
The facility failed to meet professional standards of quality by not following physician's orders for pain medication administration and by not ensuring proper documentation and orders for the use of an air mattress for a resident. The resident, who was admitted with diagnoses including cellulitis, acute respiratory failure, and emphysema, was under hospice care and had physician's orders for both scheduled and PRN morphine for pain management, as well as psychotropic medications for anxiety. Despite repeated complaints of severe pain throughout the day, the Medication Administration Record did not show that PRN morphine was administered after the morning dose, even though the resident continued to request pain relief and staff documented ongoing pain complaints. Staff interviews confirmed that no additional PRN pain medication was given prior to the resident's transfer to the hospital for pain management, and the nurse practitioner was unaware that the PRN medication had not been administered as ordered. Additionally, the facility failed to obtain or document a physician's order for the use of an air mattress, including necessary settings and specifications, for the same resident. Nursing notes indicated that the hospice team was contacted to request a new air mattress due to equipment issues, and surveyor observation confirmed the presence of an air mattress in the resident's room. However, there was no evidence in the medical record of a physician's order authorizing the use of the air mattress or specifying its settings, as acknowledged by the Assistant Director of Nursing. These deficiencies were identified through record review, staff interviews, and direct observation, and were substantiated by community complaints submitted to the state health department. The facility's failure to follow physician's orders for pain management and to ensure proper documentation and authorization for medical equipment use resulted in noncompliance with professional standards of quality care.
Failure to Document Physician-Ordered Skin Evaluations
Penalty
Summary
The facility failed to meet professional standards of quality for two residents regarding the completion and documentation of physician-ordered weekly skin evaluations. Resident ID #1, admitted in January 2023 with diagnoses including malnutrition and multiple fractures, had a physician's order dated June 30, 2024, for weekly skin evaluations. However, the Medication Administration Records for July, August, and September 2024 indicated that these evaluations were signed off as completed on several dates, but there was no evidence in the Weekly Skin Evaluation Observations to confirm that the assessments were actually performed and documented. Similarly, Resident ID #2, admitted in October 2022 with diagnoses including dementia and syncope, also had a physician's order for weekly skin evaluations dated June 30, 2024. The September 2024 Medication Administration Record showed that the evaluations were signed off as completed on two dates, but again, there was no evidence in the Weekly Skin Evaluation Observations to support that the assessments were conducted and documented. During an interview, the Director of Nursing Services was unable to provide evidence that the weekly skin assessments were completed as per the physician's orders.
Failure to Ensure Competency in Mechanical Lift Use
Penalty
Summary
The facility failed to ensure that nursing staff, specifically Nursing Assistants (NAs) Staff A and B, possessed the necessary competencies and skills to provide safe and effective care to residents. This deficiency was identified through a review of records and staff interviews, which revealed that the facility did not have evidence of completed competencies and skills sets for safe patient handling, particularly regarding the use of mechanical lifts. The facility's assessment indicated that staff training and education on mechanical lifts should be completed during orientation and annually. However, for Staff A, hired on 8/21/2024, and Staff B, hired on 8/30/2024, there was no documentation to confirm that these competencies were completed before they began providing care to residents. During an interview with the Regional Nurse, it was confirmed that the mechanical lift competencies for these staff members were not completed prior to their engagement in resident care.
Failure to Conduct Annual Performance Reviews for NAs
Penalty
Summary
The facility failed to complete an annual performance review for every nursing assistant (NA) at least once every 12 months, as required. This deficiency was identified during a record review and staff interview, which revealed that there was no evidence of completed annual performance evaluations for five NAs: Staff G, H, I, J, and K. The dates of hire for these staff members ranged from 2005 to 2023. During an interview with the Director of Nursing Services, she was unable to provide documentation of a completed performance evaluation within the last 12 months for these employees.
Failure to Provide Bedtime Snacks
Penalty
Summary
The facility failed to ensure that nourishing snacks were offered to residents at bedtime, as required by the State Operations Manual for Long Term Care. This deficiency was identified during a resident council meeting where 5 out of 9 members reported that bedtime snacks were not offered, despite expressing a desire for them. The facility's meal schedule, with supper starting at approximately 5:00 PM and breakfast at 8:00 AM, results in more than 14 hours between meals, which necessitates the provision of a bedtime snack. The Administrator acknowledged this gap and was unable to provide evidence that all residents were offered or received bedtime snacks every night.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as observed during a survey. In the main kitchen, food items such as pasta salad and hard-boiled eggs were found unlabeled and undated, violating the Rhode Island Food Code's requirement for marking refrigerated, ready-to-eat time/temperature control for safety food. Additionally, expired yogurt cups were found in two nourishment areas, and a container with an unlabeled brown substance was improperly stored with a spoon resting inside. The Food Service Director (FSD) acknowledged these issues during interviews. Further deficiencies were noted in the storage and packaging of food items. In the kitchen's freezer, chicken patties were only partially covered, and large quantities of beef patties and cookie dough balls were found in unsealed, undated bags, compromising the integrity of the food packages. The FSD was unable to provide evidence that these packages were in good condition to protect the contents from contamination. The facility also failed to maintain proper sanitation and hygiene standards. The high-temperature dishwasher did not achieve the required temperature for sanitization, as indicated by non-reactive temperature-sensitive labels. The FSD acknowledged the issue and noted that the dishwasher's thermostat was faulty. Additionally, the FSD was observed serving food without a beard restraint, and there was a lack of a certified food safety manager during certain hours of operation, as the dietary cook's certification had expired. The facility administrator could not provide evidence of a certified manager being present during these times.
Failure to Implement and Maintain Effective QAPI Program
Penalty
Summary
The facility failed to implement and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program. During a review of the QAPI binders, it was found that although QAPI plans were created for areas identified as concerns in August 2023, December 2023, and March 2024, there was no evidence of their implementation or maintenance. This included a lack of tracking and measuring performance, as well as establishing goals and thresholds for performance measurement. Similarly, the June 2024 QAPI meeting identified concerns that could aid in establishing QAPI plans, but there were no completed plans or evidence of their implementation and maintenance. During an interview with the facility Administrator, he was unable to provide evidence that the facility had implemented and maintained an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. One incident involved a Nursing Assistant, Staff B, who did not adhere to proper hand hygiene and PPE protocols while providing personal care to a resident. Staff B was observed entering a resident's room without gloves, handling a basin containing urine, and failing to perform hand hygiene before continuing with personal care tasks. This lapse in infection control practices was acknowledged by Staff B and the Director of Nursing Services. Another deficiency was noted with the improper use of PPE in a room under Contact Precautions. A housekeeper, Staff N, was observed in a resident's room without wearing gloves or additional PPE, despite the room being under Contact Precautions due to the presence of multidrug-resistant organisms (MDROs). Staff N touched various items in the room and assisted a resident without performing hand hygiene, potentially facilitating the spread of infections. This was acknowledged by Staff N during an interview with the surveyor. Additionally, the facility failed to handle, store, and transport linens appropriately. The laundry process involved moving soiled laundry through areas where clean laundry was processed, without the use of gowns unless the laundry appeared visibly soiled. Furthermore, the facility did not consistently document the regular emptying of dryer lint filters, which is a critical component of maintaining a clean and safe laundry environment. These deficiencies highlight significant lapses in the facility's infection control practices.
Deficiency in Dialysis Care for Residents
Penalty
Summary
The facility failed to provide appropriate dialysis care for two residents requiring such services, as identified during a survey. Resident ID #40, admitted with end-stage renal disease and dependent on renal dialysis, was found to have insufficient documentation regarding the care of their arteriovenous fistula (AVF). Specifically, there was no physician's order for the AVF dressing or instructions on when it should be removed post-dialysis. Additionally, the resident's thrill and bruit were not consistently assessed, with only 7 out of 70 opportunities documented since admission. During an observation, the resident was found with a dressing in place at the AVF site, but the necessary assessments were not recorded in the administration record. Similarly, Resident ID #9, also with end-stage renal disease and dependent on dialysis, lacked a physician's order for AVF dressing care. The resident was observed with an uncovered AVF and reported removing the dressing themselves after dialysis. Staff interviews revealed that the resident refused staff assistance with dressing removal, and there were no orders for AVF site dressings. The Regional Clinical Nurse confirmed the absence of such orders and acknowledged that the order to assess thrill and bruit for Resident ID #40 was not transcribed, leading to incomplete documentation of the required assessments.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with currently accepted professional principles, as observed in three out of four medication carts. On the Upper Unit medication cart, an Arnuity Ellipta inhaler was found opened and not dated, despite manufacturer instructions stating it expires six weeks after opening. On the North Unit medication cart, an Insulin Glargine Pen was also opened and not dated, with manufacturer instructions indicating it should be discarded 28 days after opening. Additionally, on the East Unit medication cart, an unopened Insulin Glargine vial was improperly stored outside of refrigeration, contrary to manufacturer instructions requiring refrigeration before opening. A Breo Ellipta inhaler was also found opened and not dated, with instructions to discard six weeks after opening. During an interview, the Regional Clinical Nurse could not explain why the insulin was stored in the medication cart and acknowledged that medications should be dated when opened.
Medication Administration Errors for Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident ID #15, who was admitted with type 2 diabetes mellitus, did not receive their prescribed Tresiba Insulin on one occasion. The family member reported that an agency nurse, identified as Staff L, was unable to locate the insulin. The Medication Administration Record (MAR) confirmed that the insulin was not administered on the specified date, and there was no documentation in the nursing progress notes indicating that the nurse informed the provider about the missed medication. Resident ID #40, admitted with end-stage renal disease and dependence on renal dialysis, did not receive their prescribed Sevelamer Carbonate on multiple occasions due to being unavailable or at dialysis. The MARs for June and July showed missed doses on several dates. During interviews, the Director of Nursing Services could not provide evidence that the medications were administered as ordered and acknowledged that the provider must be notified if a medication is not available or administered.
Communication Barriers Lead to Resident's Distress
Penalty
Summary
The facility failed to treat a Spanish-speaking resident with respect and dignity, as required by regulations, due to inadequate communication support. The resident, who has intact cognition and requires assistance with activities of daily living, was unable to effectively communicate with staff because they did not speak Spanish. This communication barrier led to the resident not receiving timely assistance for personal needs, such as using the bathroom, and not understanding the purpose of certain therapies. The resident expressed feelings of sadness and suffering due to the lack of understanding from the staff. Surveyor observations and interviews revealed that staff members, including nursing assistants and licensed practical nurses, struggled to communicate with the resident. They often relied on other staff members who spoke Spanish or used gestures, but these methods were insufficient. The facility had not provided adequate resources, such as communication boards or effective use of translation services, to bridge the language gap. The social worker acknowledged the need for an interpreter but had not addressed the resident's individual needs in a timely manner. The Director of Nursing Services was unable to explain why staff were not utilizing available translation lines to assist the resident.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to the Office of the State Long-Term Care Ombudsman for two residents who were discharged. Resident ID #75 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction and was discharged to the hospital. Resident ID #77 was admitted with hyponatremia and was discharged to their home with services. Record reviews did not show evidence that the Ombudsman was notified of these discharges. During interviews, the social worker was unable to provide evidence of such notifications.
Failure to Verify Medication Administration
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not following a physician's order for medication administration verification. The deficiency was identified through a record review and staff interviews, revealing that a resident, admitted in May 2023 with diagnoses including adult failure to thrive and pressure ulcers, did not have their medication administration verified by a second nurse as ordered. The physician's order required a second nurse verification of medication administration twice daily, but the Medication Administration Record (MAR) for May and June 2024 showed no evidence of this verification on specific dates. Interviews with Licensed Practical Nurses (LPNs) confirmed the failure to verify medication administration with a second nurse on the specified dates. LPN Staff A acknowledged not verifying the medication administration on three consecutive days in June 2024, while LPN Staff B admitted to the same oversight on a day in May 2024. The Director of Nursing Services was unable to provide evidence that the required second nurse verification occurred on these dates, as ordered by the physician.
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 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 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 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 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 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 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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