Cedar Haven Operations Holding Llc Valley View Hea
Inspection history, citations, penalties and survey trends for this long-term care facility in Woonsocket, Rhode Island.
- Location
- 4 St Joseph Street, Woonsocket, Rhode Island 02895
- CMS Provider Number
- 415079
- Inspections on file
- 28
- Latest survey
- August 5, 2025
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Cedar Haven Operations Holding Llc Valley View Hea during CMS and state inspections, most recent first.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with diabetes did not receive blood sugar checks or prescribed Humalog insulin at specific times, and was not provided a high protein bedtime snack as ordered, despite the items being available. Staff interviews confirmed the lack of documentation and failure to follow physician's orders for both medication administration and nutritional support.
A resident with multiple diagnoses, including diabetes, mood disorder, and sepsis, did not receive several ordered medications—amoxicillin-clavulanate, divalproex ER, and Lantus insulin—on multiple occasions. Documentation and staff interviews confirmed the missed doses, with staff unable to provide evidence or recall administration, and leadership unaware of the omissions.
Surveyors found that the facility failed to maintain safe water temperatures, with readings exceeding the maximum allowable limit on all floors. Staff and residents reported issues with excessively hot water, and the Maintenance Director and Administrator acknowledged the problem. This deficiency placed residents at risk for serious injury.
The facility failed to ensure the Director of Food and Nutrition Services met the qualifications of a Certified Food Safety Manager. During a survey, it was found that the Food Service Director (FSD) did not have the required certification, only presenting an expired Food Handler Training Course certificate. Both the FSD and the Administrator were unaware of the certification requirements, leading to the deficiency.
The facility failed to ensure the Director of Food and Nutrition Services was a Certified Food Safety Manager, leading to inadequate oversight of food safety practices. Observations revealed improper food storage and distribution, with meals held below safe temperatures and unlabeled or expired food items. Additionally, the facility did not maintain cleanliness in kitchen equipment, contributing to potential health risks.
The facility failed to ensure accurate assessments for residents, leading to discrepancies in medical records. Two residents undergoing dialysis had incorrect treatment status recorded, a resident with a wander guard was not coded for its use, a resident with MRSA was not coded for an active diagnosis, and another resident's discharge status was inaccurately recorded. These issues were acknowledged by the facility's staff during surveyor interviews.
The facility failed to review and revise the care plans of 29 residents following their comprehensive and quarterly assessments. Despite completing MDS assessments, there was no evidence of care plan updates by the interdisciplinary team. Staff interviews revealed that care plan meetings were not consistently held due to staffing constraints, and physicians and nursing assistants were not typically included. Additionally, residents and family members were not adequately involved in care plan meetings.
The facility failed to follow protocols for Narcan administration, medication orders, and wound care. A resident received Narcan without meeting overdose criteria, and two residents did not receive prescribed medications due to lapses in ordering and administration. Additionally, a resident's Valproic Acid levels were not monitored, and proper wound care techniques were not followed, indicating significant lapses in care standards.
A facility failed to provide proper respiratory care for a resident requiring suctioning. The resident, with conditions like dysphagia and aspiration pneumonia, had a physician's order for suctioning as needed. Observations revealed undated suction equipment with secretions, and staff were unsure about maintenance protocols. The DON expected equipment to be dated and discarded after 24 hours, but records lacked evidence of proper procedures.
The facility failed to properly store and label medications, with several instances of opened medications lacking dates, contrary to manufacturer instructions. Additionally, a discrepancy in the narcotic count for a resident's Oxycodone was noted, as a nurse failed to document the administration in both the narcotic log and EMAR.
The facility failed to maintain an effective infection prevention and control program, with staff not adhering to contact precautions and enhanced barrier precautions (EBP) for residents with MDROs and chronic wounds. Instances included staff entering rooms without proper PPE and inadequate signage for precautions. Additionally, laundry handling practices did not comply with infection control policies, as staff did not consistently wear gowns when handling soiled laundry.
The facility failed to provide required training for new hires, including the FSD and three other staff members, as outlined in their Facility Assessment. The training topics not covered included abuse, neglect, corporate compliance, cultural competency, and more. The Administrator confirmed that these staff members did not attend the mandatory orientation where the training was supposed to be provided.
The facility failed to serve food at safe and appetizing temperatures, as observed during a survey. Multiple residents reported that their meals were consistently served cold and unappetizing. The Food Service Director confirmed that the standard practice involved leaving food uncovered and exposed, leading to decreased temperatures. Temperature checks revealed that food items were below the safe holding temperature of 135°F, with some as low as 102°F.
The facility hired a Maintenance Assistant with a disqualifying criminal record for domestic violence, despite regulations prohibiting such employment. The Administrator misunderstood the status of the charges, believing they were dismissed. The employee has not returned to the facility since the issue was identified.
A resident with leg amputations developed a knee wound that was not properly documented or managed according to professional standards. The wound lacked a physician's order for care, and there was no documentation of its characteristics. Staff interviews confirmed these deficiencies, and the wound was observed to be inadequately dressed.
A resident with a stage 3 pressure ulcer did not receive proper wound care as a nurse used a multiuse jar of Silvadene cream, applying it directly with a gloved finger, contrary to the facility's no-touch policy. The nurse acknowledged the error, and the DON confirmed that multiuse supplies should not enter a resident's room and an applicator should be used.
A facility failed to provide appropriate care for a resident with a nephrostomy tube by not transcribing and executing a hospital discharge order to flush the PCN tube daily. The resident confirmed the tube was last flushed in the hospital, and staff were unaware of the oversight until informed by a surveyor.
A resident with lupus anticoagulant syndrome and a history of pulmonary embolism experienced a significant medication error when the facility failed to increase their warfarin dosage from 3.5 mg to 4 mg as ordered by a physician. The facility also did not conduct a follow-up INR test as required, leading to a low INR value of 1.4, increasing the risk of blood clot development. Staff interviews confirmed the oversight in medication management and monitoring.
The facility failed to provide timely lab services for two residents, leading to deficiencies in care. One resident on warfarin did not receive a timely INR test, increasing their risk for blood clots. Another resident with elevated WBCs did not have a urinalysis completed as ordered, and the provider was not notified promptly. This resident's condition worsened, leading to hospitalization and eventual transition to hospice care. Staff interviews confirmed the lack of adherence to facility policies for timely lab follow-up and notification.
The facility failed to maintain a safe and sanitary environment across all nursing units, with issues such as stained ceiling tiles, dusty vents, and unclean shower rooms. Residents reported long-standing problems, and staff were unaware of these conditions. The facility's inspection and maintenance records did not document these deficiencies, leading to ongoing environmental issues.
A resident with dementia, identified as a moderate risk for wandering, eloped from a secured unit due to the facility's failure to reassess and implement interventions like a wanderguard or frequent checks. The resident was found 1.5 miles away, confused and disoriented, after being last seen eating dinner. The facility was unaware of the elopement until contacted by a hospital.
A facility failed to ensure nursing staff had the necessary competencies for PICC line care, affecting a resident who required IV antibiotics. Only 6 out of 60 nurses were trained in PICC line care, and the Director of Nursing could not provide evidence of completed competencies for all nurses.
A resident with multiple health conditions did not receive critical medications, including methadone and an antibiotic, over three days due to the facility's failure to ensure timely delivery from pharmacies. The issue arose from a late order submission to the methadone pharmacy, resulting in missed doses and inadequate pharmaceutical care.
A resident in an LTC facility missed five doses of methadone and one dose of Daptomycin due to late submission of medication orders to the pharmacy, resulting in significant medication errors. The resident, with a history of opioid abuse and other medical conditions, did not receive these critical medications as confirmed by the DON and an LPN during a survey following a complaint.
A resident with a stage 4 pressure ulcer on the sacrum did not receive prescribed Acetaminophen for pain management prior to a wound treatment. During the procedure, the resident showed signs of distress, such as yelling and swearing. The LPN responsible for the wound care admitted to not administering pain medication before treatments, which was against professional standards and the resident's documented needs. The DON highlighted the expectation for pain medication to be given before wound treatments and for the procedure to be halted if pain management was not provided.
The facility failed to store and distribute food according to professional standards, with unlabeled food items and improper use of sanitizer chemicals. Additionally, ice machines lacked required air gaps, and the main kitchen had a heavy accumulation of dust on hood slats.
The facility failed to administer prescribed medications to six residents due to unavailability and did not notify practitioners of the missed doses. Staff interviews confirmed the medication shortages and lack of notification, and the Director of Nursing acknowledged the issue.
The facility failed to maintain an infection prevention and control program, as evidenced by improper wound dressing changes and inadequate hand hygiene during medication administration. Staff did not follow proper procedures for glove use and hand hygiene, leading to potential risks of infection transmission.
The facility failed to report a fracture of unknown origin in a resident's left knee to the Rhode Island Department of Health as required by their policy. The resident, who had a stage 4 pressure ulcer, muscle weakness, and dementia, was transferred to a hospital after an x-ray revealed the fracture. A registered nurse confirmed the injury was not reported to the appropriate authorities.
The facility failed to follow physician's orders for several residents, including maintaining oxygen levels for a resident with COPD, applying heel booties for a resident with a pressure ulcer, using a knee splint for a resident with contractures, and elevating legs for a resident with lymphedema. Staff were either unaware of the orders or did not document their application, compromising the quality of care.
The facility failed to provide appropriate treatment and services for two residents with indwelling catheters. Despite physician orders, there was no documentation of urinary output or adherence to catheter maintenance protocols. Staff interviews revealed a lack of clarity and adherence to protocols regarding the monitoring and documentation of urinary output.
The facility failed to maintain a medication error rate below 5%, with two residents not receiving their prescribed medications as ordered. The errors were acknowledged by an RN, and the DON confirmed the expectation for proper medication administration.
The facility failed to maintain accurate medical records for two residents. One resident with a stage 4 pressure ulcer did not have heel boots applied as ordered, and another resident with varicose veins and open wounds did not have their wounds off-loaded as documented. Staff were unable to explain the discrepancies.
The facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) of Non-coverage Form to two residents discharged from Medicare Part A services, as required by Medicare guidelines. Staff interviews confirmed the oversight, but no evidence of the forms being issued was found.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Follow Physician's Orders for Insulin Administration and Nutritional Support
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by not following physician's orders for a resident with diabetes mellitus. Specifically, there was a physician's order for Humalog insulin to be administered according to a sliding scale based on blood sugar readings. However, documentation was missing to show that the resident's blood sugar was obtained at two specified times, which was necessary to determine if insulin administration was required. Additionally, there was a physician's order for a high protein snack at bedtime for nutritional support, but the snack was not provided on two occasions, despite the items being available in the facility. During interviews, an LPN was unable to explain why the high protein snack was not given and could not provide evidence that blood sugar checks were performed as ordered. The President of Operations also confirmed that the required snack items were available and acknowledged the lack of documentation for the blood sugar checks. These findings indicate that the facility did not consistently follow physician's orders for medication administration and nutritional support for the resident.
Failure to Administer Critical Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by multiple missed doses of critical medications. Upon readmission, the resident had diagnoses including diabetes mellitus, mood disorder, and sepsis. Physician orders were in place for amoxicillin-clavulanate for sepsis, divalproex ER for mood disorder, and Lantus insulin for diabetes. Record review showed that the amoxicillin-clavulanate was not administered as ordered on one occasion, with documentation indicating it was still on order despite being available in the facility’s automated medication dispensing system. The divalproex ER was not administered on two consecutive days, and the Lantus insulin was not given as ordered on one day, with no evidence provided to confirm administration. Staff interviews revealed that the LPN assigned to the resident could not recall administering the Lantus insulin and acknowledged the missed doses of both amoxicillin-clavulanate and divalproex ER. The nurse practitioner was unaware of the missed doses and expected the medications to have been administered as ordered. The President of Operations also confirmed expectations that the medications should have been given and could not provide an explanation for the missed doses. These findings demonstrate a failure to follow physician orders and facility policy regarding timely and accurate medication administration.
Unsafe Water Temperatures in Facility
Penalty
Summary
The facility failed to maintain safe water temperatures, as observed by surveyors on all four floors. During the survey, water temperatures in various locations, including resident rooms and shower rooms, were found to exceed the maximum allowable limit of 118 degrees Fahrenheit, with some readings as high as 137.7 degrees Fahrenheit. This was confirmed through direct observation and measurement by surveyors using digital thermometers. Staff interviews revealed that nursing assistants were aware of the potential for water to become too hot, and one resident reported that the water in their room was too hot to use after maintenance work. The Maintenance Director and the Administrator, along with the Director of Nursing Services, acknowledged the excessive water temperatures and the lack of evidence to ensure a safe environment regarding water temperatures. The facility's failure to control water temperatures placed residents at risk for serious injury, as the temperatures recorded were high enough to cause burns. The deficiency was identified through surveyor observations, staff interviews, and resident feedback, highlighting a significant lapse in maintaining a safe and compliant environment for residents.
Deficiency in Food Safety Manager Certification
Penalty
Summary
The facility failed to ensure that the Director of Food and Nutrition Services met the minimum qualifications of a Certified Food Safety Manager, as required by the Rhode Island Food Code, 2018 Edition. During an initial tour of the main kitchen, surveyors did not find evidence of a certification for the Food Service Director (FSD). Although the FSD claimed to have obtained the necessary education and certification, he was unable to present the appropriate documentation at the time. Instead, he provided a Certificate of Completion for a Food Handler Training Course, which did not meet the regulatory requirements and was expired. Further interviews revealed that both the FSD and the Administrator were unaware of the certification requirements and the expiration of the provided certificate. The Administrator admitted that she was not aware that the FSD did not possess the required certifications upon his hire in November 2024. This lack of awareness and oversight led to the deficiency, as the facility did not have a certified individual with supervisory and management responsibility over food preparation and service, as mandated by the regulations.
Deficiencies in Food Safety Management and Practices
Penalty
Summary
The facility failed to ensure that the Director of Food and Nutrition Services met the minimum qualifications of a Certified Food Safety Manager. During the survey, it was observed that the Food Service Director (FSD) did not possess the required certification, and the facility was unable to provide evidence of a Certified Food Safety Manager being present during all meal services for significant periods in January and February. The FSD was unaware of the certification requirements, and the facility's administrator was also unaware of the FSD's lack of certification upon hire. The facility also failed to maintain proper food storage and distribution practices. During a surveyor observation, it was noted that food was not held at the required temperatures, with several plated meals showing temperatures below the safe holding temperature of 135°F. The FSD was unaware of the potential hazards of low holding temperatures until informed by the surveyor, and dietary staff were not informed of the unsafe temperatures, leading to the potential distribution of unsafe meals. Additionally, the facility did not adhere to proper labeling and dating of food items, as required by the Rhode Island Food Code. Numerous food items in the main kitchen and kitchenettes were found unlabeled or with expired discard dates. The FSD was unaware of the facility's policy regarding the use and storage of food brought in by visitors. Furthermore, the facility failed to maintain cleanliness in food contact surfaces, with observations of accumulated residue and dirt in various kitchen equipment and storage areas.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate assessments for several residents, leading to discrepancies in their medical records. For two residents undergoing dialysis, the assessments did not accurately reflect their treatment status. One resident was incorrectly marked as receiving dialysis when there was no evidence of such treatment, while another resident who was dependent on dialysis was not marked as receiving it during the assessment period. Additionally, a resident with a wander guard was not coded for its use, despite physician orders indicating daily checks and functionality tests. Further discrepancies were noted in the assessment of a resident with a methicillin-resistant Staphylococcus aureus (MRSA) infection, as the resident was not coded for having an active diagnosis of a multidrug-resistant organism. Another resident's discharge status was inaccurately recorded, showing a planned discharge to the hospital instead of the actual discharge home with services. These inaccuracies were acknowledged by the facility's MDS Coordinator and Administrator during surveyor interviews.
Failure to Review and Revise Resident Care Plans
Penalty
Summary
The facility failed to review and revise the care plans of 29 long-term care residents following their comprehensive and quarterly assessments. This deficiency was identified through record reviews and staff interviews, which revealed that the interdisciplinary team did not update the care plans as required. The residents involved had various diagnoses, including diabetes mellitus type 2, chronic heart failure, anxiety disorder, epilepsy, dementia, and other chronic conditions. Despite the completion of the Minimum Data Set (MDS) assessments, there was no evidence that the care plans were reviewed and revised accordingly. Interviews with staff, including the MDS Nurse and the Director of Nursing Services, indicated that care plan meetings were supposed to be held quarterly. However, it was revealed that these meetings were not consistently conducted, and documentation of such meetings was lacking. The MDS Nurse admitted that due to staffing constraints, she sometimes had to work on the floor, which prevented her from holding the required care plan meetings. Additionally, it was noted that physicians and nursing assistants were not typically included in these meetings, which could have contributed to the oversight in updating the care plans. Further interviews with residents and family members highlighted a lack of involvement in care plan meetings. A family member of one resident was unaware of what a care plan meeting was and had never attended one. Similarly, during a Resident Council task, multiple residents indicated that they were not typically involved in care plan meetings. This lack of involvement and communication with residents and their families further underscores the facility's failure to adhere to the required processes for reviewing and revising care plans, as mandated by regulations.
Facility Fails to Adhere to Medication and Treatment Protocols
Penalty
Summary
The facility failed to adhere to its policy on Narcan administration for a resident who was readmitted with diagnoses including seizures and muscle weakness. The resident exhibited symptoms such as slurred speech and dilated pupils, but these were not indicative of an opioid overdose according to the facility's policy. Despite this, Narcan was administered without completing a Substance Use Disorder (SUD) assessment upon admission, and the facility did not call 911 as required by their policy. Staff interviews revealed a lack of familiarity with the Narcan policy and an inability to provide evidence of the necessary assessments. In another instance, the facility did not follow physician orders for two residents regarding medication administration. One resident with ocular hypertension did not receive prescribed Latanoprost eye drops for several weeks, despite the medication being signed off as administered. The eye drops were not available at the resident's bedside, and the pharmacy had not been contacted to reorder them. Another resident with a right hallux infection did not receive the podiatrist's recommended treatment, as the orders were not implemented by the nursing staff. Additionally, the facility failed to monitor blood levels for a resident receiving Valproic Acid, a medication requiring regular monitoring. The resident had been on the medication since April 2024, but there was no evidence of blood level monitoring until the issue was raised by the surveyor. Furthermore, a resident with a non-pressure wound did not receive proper wound care, as the LPN failed to perform hand hygiene between glove changes and did not apply the dressing as ordered. These deficiencies highlight significant lapses in following professional standards of practice and physician orders, impacting the quality of care provided to the residents.
Failure to Maintain Proper Suction Equipment Protocol
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident who required suctioning. The resident, admitted with conditions including dysphagia, aspiration pneumonia, and acute respiratory failure, had a physician's order for suctioning as needed for increased secretions. On February 19, 2025, the resident was noted to have increased secretions and was suctioned with good effect. However, during surveyor observations from February 24 to February 26, 2025, a suction canister and tubing were found without a date, containing multi-colored secretions and tan-colored fluid, indicating improper maintenance and potential infection control issues. Interviews with staff revealed a lack of knowledge regarding the last use of the suction machine, the duration the secretions had been in the canister, and the protocol for cleaning or changing the equipment. The Director of Nursing Services stated that the canister and tubing should have been dated and discarded after 24 hours, but there was no evidence in the records of when the equipment should be changed, cleaned, or replaced. This lack of adherence to the facility's policy for suctioning a patient contributed to the deficiency in providing safe and appropriate respiratory care.
Medication Storage and Documentation Deficiencies
Penalty
Summary
The facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles. During a surveyor observation, it was found that several medication carts and storage rooms contained medications that were opened without being dated. Specifically, a bottle of Lorazepam Intensol, a protein supplement, and several inhalers were found opened without dates, despite manufacturer instructions requiring them to be discarded after a certain period post-opening. Staff members, including a Licensed Practical Nurse and Certified Medication Technicians, acknowledged the oversight during interviews, admitting that medications should be dated when opened. Additionally, there was a discrepancy in the narcotic count for a resident prescribed Oxycodone. The narcotic count log indicated 27 tablets remaining, while the pharmacy blister pack showed 26 tablets, suggesting one tablet was unaccounted for. A Registered Nurse admitted to administering the medication but failed to document it in both the narcotic count log and the Electronic Medication Administration Record (EMAR). The facility's Administrator and Director of Nursing Services expressed expectations that medications be dated when opened and that the administration of controlled substances be properly documented.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of non-compliance with contact precautions and enhanced barrier precautions (EBP). For Resident ID #83, who was on contact precautions due to a Methicillin-resistant Staphylococcus Aureus (MRSA) infection, a nursing assistant entered the resident's room without wearing the required gown and gloves, despite signage indicating the need for such precautions. This lapse was acknowledged by the staff involved and confirmed by the Infection Preventionist. Additionally, the facility did not adhere to its policy for discontinuing isolation precautions for Residents ID #25 and #38, both of whom had been treated for infections with multidrug-resistant organisms (MDROs). There was no evidence of negative screenings 48 hours after the completion of antibiotic therapy, which is required to remove residents from contact precautions. The Infection Preventionist and the Director of Nursing Services (DNS) were unable to provide documentation of these screenings, and signage indicating contact precautions was missing from the residents' rooms. The facility also failed to implement EBP for residents with chronic wounds. Resident ID #3, with a stage 3 pressure wound, did not have EBP in place, and staff did not wear gowns during wound care. Similarly, Resident ID #123, who was on EBP, received care without staff wearing gowns, contrary to posted signage. Resident ID #161, with a chronic wound, was not placed on EBP, and there was no signage indicating the need for such precautions. Furthermore, the facility's laundry handling practices were inadequate, as staff did not consistently wear gowns when handling soiled laundry, including items from precaution rooms, as required by facility policy.
Failure to Implement Effective Training Program for New Hires
Penalty
Summary
The facility failed to implement and maintain an effective training program for newly hired employees, as required by their Facility Assessment. The assessment outlined specific training topics that should be covered upon hire and annually for all staff, including abuse, neglect, mandatory reporting, corporate compliance, cultural competency, customer service, dementia care, disaster planning, emergency preparedness, Heimlich maneuver, HIPAA, infection control, residents' rights, workplace safety, and COVID-19. However, a review of training records revealed that four out of five newly hired employees, including the Food Service Director and three other staff members, did not receive the required training upon hire. During interviews with the Administrator, it was revealed that new employees only received education on workplace violence, harassment, and sexual harassment on their first day. The Administrator acknowledged that the staff members in question did not attend the mandatory orientation where the rest of the required training was supposed to be provided. Furthermore, there was no evidence to show that the necessary in-services were completed for these employees upon hire, as stipulated in the Facility Assessment.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food that is palatable, attractive, and at an appetizing temperature, as required by the Rhode Island Food Code. A community-reported complaint highlighted concerns about hot food items being served cold. During the survey, multiple residents, including those with moderate protein-calorie malnutrition, type 2 diabetes, and anxiety disorder, reported that their meals were consistently served cold and unappetizing. The residents expressed dissatisfaction with the temperature and quality of the food, indicating a failure to meet their expectations for hot meals. Surveyor observations during the lunch meal plating process revealed that food items were left uncovered and exposed for extended periods, leading to a decrease in temperature. The Food Service Director (FSD) confirmed that the standard practice involved plating meals and leaving them stationary for over 90 seconds before covering and transporting them. Temperature checks conducted by the FSD, at the surveyor's request, showed that the food temperatures were below the safe holding temperature of 135 degrees Fahrenheit, with some items as low as 102 degrees Fahrenheit. The FSD acknowledged being unaware of the required safe holding temperatures prior to the surveyor's intervention.
Facility Hired Employee with Disqualifying Criminal Record
Penalty
Summary
The facility failed to ensure compliance with regulations prohibiting the employment of individuals with a history of abuse or mistreatment. Specifically, the facility hired a Maintenance Assistant, referred to as Staff A, who had disqualifying information on his criminal background check. The background check, conducted by the Bureau of Criminal Identification (BCI), revealed that Staff A had been convicted of domestic violence-related charges, including simple assault and disorderly conduct. Despite this, the facility proceeded with his employment, and he was working independently as a team leader on the 2nd floor. The Administrator was aware of the disqualifying information but misunderstood the status of the charges, believing they had been dismissed. Staff A had informed the Administrator that he had completed all sentencing components, including probation and therapeutic services, leading to the impression that the charges were resolved. However, documentation provided by Staff A confirmed his conviction. Following the surveyor's identification of this issue, Staff A has not returned to the facility, and his employment status remains undetermined.
Failure to Document and Manage Resident's Wound
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive care plan. The resident, who was readmitted to the facility with diagnoses including acquired absence of both legs, developed an abrasion on the right knee, which later became a wound. Despite the presence of the wound, there was no physician's order for wound care, nor was there documentation of the wound's characteristics as required by regulation. During a surveyor observation, it was noted that the wound dressing on the resident's right knee was dated three days prior to the observation, and there was no evidence that the physician had been notified of the wound. Interviews with staff, including an LPN and the Director of Nursing Services, confirmed the lack of documentation and physician notification. The wound was observed to be covered with blood, and upon cleaning, it was revealed to be a U-shaped wound, further highlighting the deficiency in care and documentation.
Improper Wound Care Technique and Infection Control Breach
Penalty
Summary
The facility failed to ensure proper pressure ulcer care for a resident with a stage 3 pressure wound on the left lateral foot. The resident, who was readmitted to the facility with a diagnosis including type 2 diabetes mellitus, had a wound with light serous drainage that had persisted for over 138 days. A physician's order was in place to cleanse the wound, apply skin prep, Silvadene cream, and cover it with gauze daily. However, during a surveyor observation, a registered nurse used a multiuse jar of Silvadene, applying the cream directly with a gloved finger, contrary to the facility's policy of using a no-touch technique. The nurse acknowledged the improper technique and returned the multiuse jar to the treatment cart, which was against the facility's infection control policy. The Director of Nursing Services confirmed that multiuse supplies should not be brought into a resident's room and that an applicator should be used for applying creams. This failure to adhere to proper wound care procedures and infection control measures led to the deficiency identified by the surveyors.
Failure to Transcribe and Execute PCN Tube Flushing Order
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a nephrostomy tube. The resident was admitted with a diagnosis of obstructive and reflux uropathy and had a hospital discharge order to irrigate the PCN tube with 10 milliliters of normal saline daily and as needed. However, there was no evidence that the PCN tube was flushed for 21 days following admission. The resident confirmed that the tube was last flushed in the hospital before arriving at the facility. A registered nurse revealed that the order to flush the PCN tube was never transcribed, and the nurse practitioner was unaware that the order was not being completed until informed by the surveyor. The facility administrator acknowledged that the hospital order should have been transcribed and the PCN tube flushed daily.
Failure to Administer Correct Warfarin Dosage and Monitor INR Levels
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors related to the administration of warfarin, an anticoagulant medication. The resident, who was readmitted to the facility with lupus anticoagulant syndrome and a history of pulmonary embolism, had a physician's order to increase their warfarin dosage from 3.5 mg to 4 mg daily after a lab result showed a low INR value of 1.8. However, the facility did not implement this order, and the resident continued to receive the lower dosage. Additionally, the facility did not conduct a follow-up INR test one week after the order, as required. Interviews with facility staff, including a Nurse Practitioner, a Licensed Practical Nurse, and the Director of Nursing Services, confirmed that the order to increase the warfarin dosage was not transcribed, and the INR test was not repeated as directed. The deficiency was further highlighted when a subsequent INR test, conducted after the surveyor's intervention, showed an even lower INR value of 1.4, indicating an increased risk for blood clot development. This oversight in medication management and monitoring led to a significant medication error for the resident.
Failure to Provide Timely Laboratory Services for Residents
Penalty
Summary
The facility failed to provide timely laboratory services for two residents, leading to deficiencies in care. For Resident ID #23, who was prescribed warfarin to prevent blood clots, the facility did not obtain an INR test as ordered by the Nurse Practitioner (NP) one week after a low INR value was identified. This oversight persisted for 21 days, during which no INR test was conducted, despite the resident's increased risk for blood clot development. Interviews with staff, including the NP and the Director of Nursing Services (DNS), confirmed the failure to follow through with the ordered laboratory test. For Resident ID #420, who had a history of neutropenia and sepsis, the facility did not complete a urinalysis with culture and sensitivity (U/A C&S) as ordered by the physician due to an elevated white blood cell (WBC) count. The facility also failed to notify the provider in a timely manner about the inability to obtain the urine specimen and the elevated WBC results. The resident's condition worsened, leading to hospitalization, where further elevated WBC levels were recorded, and the resident eventually transitioned to hospice care and expired. The facility's policies required prompt follow-up on abnormal lab results and timely notification of prescribing practitioners, which were not adhered to in these cases. Interviews with staff, including the NP and the Administrator, revealed a lack of evidence for timely reporting and completion of the required laboratory tests, contributing to the deficiencies in care for both residents.
Environmental Deficiencies in Facility's Nursing Units
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment across all four nursing units, as evidenced by surveyor observations and interviews. The survey revealed several deficiencies, including stained ceiling tiles, dusty vents, rusted metal frames, and accumulations of yellow and brown matter on walls and floors in common shower rooms. Additionally, broken plaster and protruding metal were found on a door frame, and feces were identified on the floor of a shower stall. These issues were not documented in the facility's environmental inspection records or maintenance logs, indicating a lack of awareness and action by the maintenance staff and administration. Residents reported long-standing issues with stains on their ceilings and unclean common shower rooms, which were confirmed by surveyor observations. Interviews with nursing staff revealed they were unaware of the conditions in the common shower rooms, and the Administrator acknowledged the deficiencies upon surveyor observation. The facility's failure to include these areas in their monthly inspections and maintenance logs contributed to the ongoing environmental issues, impacting the residents' living conditions.
Failure to Supervise Resident at Risk for Wandering
Penalty
Summary
The facility failed to provide adequate supervision and implement necessary interventions for a resident identified as a moderate risk for wandering. The resident, who was admitted with dementia and resided in a secured unit, displayed exit-seeking behavior but was not reassessed for wander risk, nor were interventions such as a wanderguard or frequent checks implemented as per facility policy. The care plan was not updated to address the resident's wandering behavior, despite previous indications of agitation and attempts to leave the facility. On the day of the incident, the resident was last seen by staff eating dinner in the dayroom. However, the facility was unaware of the resident's elopement until notified by a hospital, where the resident was taken after being found by a jogger approximately 1.5 miles from the facility. The resident was confused and unable to recall their location or the date. The facility's failure to follow its policy and implement necessary interventions resulted in the resident leaving the secured unit and exiting the facility unsupervised.
Deficiency in Nursing Competency for PICC Line Care
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skill sets to provide safe nursing and related services, specifically concerning the care of a peripherally inserted central catheter (PICC) line. This deficiency was identified for a resident who was admitted with a PICC line and required intravenous (IV) antibiotics once every 24 hours. The facility's assessment indicated the capability to provide IV therapy, yet a review of the 2024 Education Series for Registered Nurses and Licensed Practical Nurses showed no evidence of education, competencies, or skill sets related to PICC line care or IV therapy administration. Further investigation revealed that only 6 out of 60 nurses had received training in midline and PICC dressing and removal, as per a 2022 RIHCA Competency Training document. During an interview, the Director of Nursing Services was unable to provide evidence that all Registered Nurses and Licensed Practical Nurses had completed PICC line competencies and skill sets. This lack of comprehensive training and competency verification for all nursing staff led to the deficiency in ensuring resident safety concerning PICC line care.
Failure to Provide Pharmaceutical Services
Penalty
Summary
The facility failed to provide necessary pharmaceutical services to meet the needs of a resident, identified as Resident ID #1, who was admitted with multiple diagnoses including sepsis, history of opioid abuse, type II diabetes mellitus, acute kidney injury, and infection due to an internal fixation device. The resident did not receive critical medications, including methadone and an antibiotic, over a period of three days. Specifically, the resident missed five doses of methadone and one dose of daptomycin-sodium chloride intravenous solution due to the unavailability of these medications. The deficiency was identified following a community-reported complaint to the Rhode Island Department of Health, which alleged that the resident had not received methadone and other medications for two days. The facility's Director of Nurses and an LPN confirmed that the medications were not administered because they were not delivered by the pharmacies. The pharmacy responsible for delivering methadone received the order too late to fulfill it on time, as their courier had already left for the day. This situation highlights a breakdown in the facility's process for acquiring and administering medications, resulting in the resident not receiving essential pharmaceutical care.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the missed administration of methadone and Daptomycin-Sodium Chloride Intravenous Solution. The resident, who was admitted in June 2024 with a history of opioid abuse, sepsis, type II diabetes mellitus, acute kidney injury, and infection due to an internal fixation device, did not receive five doses of methadone over a three-day period. The methadone was not administered on the morning and evening of June 18th and 19th, and the morning of June 20th. This lapse occurred because the facility submitted the methadone order paperwork to the pharmacy too late on June 18th, missing the daily delivery schedule. Additionally, the resident did not receive a scheduled dose of Daptomycin-Sodium Chloride Intravenous Solution on June 18th. During interviews, the Director of Nursing Services and a Licensed Practical Nurse confirmed that the resident missed these critical medications. The failure to administer these medications was identified during a survey following a community-reported complaint to the Rhode Island Department of Health.
Inadequate Pain Management During Wound Care Procedure
Penalty
Summary
The facility failed to ensure appropriate pain management for Resident ID #79, who had a stage 4 pressure ulcer on the sacrum upon readmission in March 2024. Despite a physician's order for Acetaminophen for pain management, the resident did not receive any pain medication prior to a wound treatment observed on 3/13/2024. During the treatment, the resident exhibited signs of distress, including yelling and swearing, indicating inadequate pain control during the procedure. Staff M, the Licensed Practical Nurse responsible for the wound care, acknowledged not medicating the resident before treatments, contrary to professional standards and the resident's documented need for pain management. The deficiency in pain management for Resident ID #79 was further highlighted by the Director of Nursing Services, who expressed expectations for the resident to be medicated before wound treatments and for the nurse to halt the procedure if pain medication was not administered.
Food Safety and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and distributed in accordance with professional standards for food safety. During an initial tour of the main kitchen, surveyors observed unlabeled food items, including two bags of hard-boiled eggs in clear liquid and an opened plastic bag of French toast with freezer burn. The Food Service Director (FSD) acknowledged these items and indicated they should be discarded. Additionally, the hood slats in the main kitchen were noted to have a heavy accumulation of dust, which the FSD also acknowledged. Furthermore, a Dietary Aide was observed washing hotel pans and sheets in the 3-bay sink without using the appropriate test strips to test the sanitizer chemicals, revealing a lack of knowledge about the necessity of test strips and the correct procedure for using the chemicals. The facility also failed to maintain proper air gaps for ice machines. During observations, it was noted that the second-floor ice machine and the main kitchen's ice machine did not have the required air gaps. The drain below the air pipe of the second-floor ice machine was observed to have a dark substance. Both the FSD and the Maintenance Director acknowledged the absence of air gaps in the ice machines. The Maintenance Director further revealed that the second-floor ice machine is used frequently, emphasizing the importance of maintaining proper air gaps to ensure food safety.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to keep residents free from significant medication errors for six residents. Resident ID #48 did not receive Ambien and Oxycodone on multiple dates in March 2024 due to the medications being unavailable. The Nurse Practitioner was unaware of the missed doses until informed by the surveyor. Similarly, Resident ID #7 missed doses of Lexapro, Fluticasone Propionate, and Artificial Tears due to unavailability, and there was no evidence that the practitioner was notified of these missed medications. Resident ID #42 missed doses of Zoloft, Resident ID #70 missed doses of Carvedilol and Hypromellose, Resident ID #112 missed doses of Lorazepam, and Resident ID #123 missed doses of Buspirone, all due to the medications being unavailable. In each case, there was no evidence that the practitioners were notified of the missed doses until the surveyor brought it to the facility's attention. Interviews with staff confirmed the unavailability of medications and the lack of notification to practitioners. The Director of Nursing Services acknowledged that the medications were not administered and were coded as unavailable. The facility did not provide evidence that they kept residents free from significant medication errors, as required by their policy on medication administration. The facility also had an emergency kit available, but it was not utilized to address the medication shortages in a timely manner.
Infection Control Deficiencies in Wound Care and Medication Administration
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by improper wound dressing changes and inadequate hand hygiene during medication administration. For Resident ID #87, a registered nurse did not remove dirty gloves, perform hand hygiene, or don new gloves before cleansing a wound, contrary to facility policy. Similarly, for Resident ID #105, a licensed practical nurse and a nursing assistant failed to change gloves and disinfect a multi-use wound cleanser bottle after handling a wound with copious drainage, which is against infection control practices. Additionally, during medication administration, a registered nurse did not perform hand hygiene between resident encounters. The nurse entered and exited multiple residents' rooms without washing hands or using alcohol gel, even when signs indicated the necessity of hand hygiene. The nurse also wore dirty gloves while administering an injection and walked down the hallway without disposing of the gloves, which is a breach of the facility's medication administration policy. Interviews with the involved staff and the Director of Nursing Services confirmed the lapses in infection control practices. The staff acknowledged their failure to adhere to proper procedures, and the Director of Nursing Services expressed that she would expect staff to follow the correct infection control protocols. The facility's infection preventionist also confirmed the expectation for staff to perform hand hygiene before and after each resident encounter.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, including injuries of unknown origin, were reported immediately to the appropriate authorities. Specifically, the facility did not report a fracture of unknown origin in a resident's left knee to the Rhode Island Department of Health as required by their policy. The resident, who was readmitted to the facility in February 2024 with diagnoses including a stage 4 pressure ulcer, muscle weakness, and dementia, was found to have a fracture in the upper portion of the patella as revealed by an x-ray on March 13, 2024. During an interview, a registered nurse confirmed that the resident was transferred to an acute care hospital after the x-ray revealed the fracture. However, the nurse was unable to provide evidence that this injury of unknown origin was reported to the Rhode Island Department of Health. This failure to report the injury in a timely manner is a violation of the facility's policy and state regulations.
Failure to Follow Physician's Orders
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by not following physician's orders for several residents. Resident ID #3, who was readmitted with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure, had orders to maintain oxygen saturation between 88-92%. However, records and observations revealed that the resident's oxygen levels were frequently outside this range, and staff did not adjust the oxygen flow as required. Additionally, the resident was observed with an oxygen saturation level of 100%, which was not within the prescribed parameters, and staff acknowledged this discrepancy during interviews. Resident ID #66, who had a stage 4 pressure ulcer and other conditions, had a physician's order for heel booties to be worn every shift. Multiple observations showed that the resident was not wearing the heel booties, and staff were unable to locate one of the booties. The Director of Nursing Services (DNS) confirmed that staff were expected to follow the physician's orders. Similarly, Resident ID #75, who had contractures and a stage 4 pressure ulcer, had an order for a right knee splint to be applied daily. Observations revealed that the resident was not wearing the knee splint, and staff were either unaware of the order or did not document its application. Resident ID #105, who had varicose veins, open wounds, and lymphedema, had orders to elevate legs and off-load wounds every shift. Observations showed that the resident's legs were not elevated, and wounds were not off-loaded. The resident expressed a preference for a recliner to elevate legs instead of staying in bed, but staff were unaware of this preference. The DNS indicated that staff were expected to follow the physician's orders but was not aware of the resident's need for a recliner. These deficiencies highlight the facility's failure to adhere to physician's orders, compromising the quality of care provided to the residents.
Failure to Monitor and Document Urinary Output for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to provide appropriate treatment and services for two residents with indwelling catheters. Resident ID #79 was readmitted to the facility with diagnoses including retention of urine and obstructive and reflux uropathy. Despite having physician orders to flush the catheter and PCN tube and monitor urinary output, these orders were not re-initiated upon the resident's return from the hospital. Additionally, there was no documentation of urinary output for the month of March 2024. Interviews with staff revealed a lack of clarity and adherence to protocols regarding the monitoring and documentation of urinary output and catheter maintenance. Resident ID #129 was admitted with diagnoses including a urinary tract infection and obstructive and reflux uropathy. The resident's care plan indicated the presence of a foley catheter, but there was no documentation of urinary output to monitor for urine output. The DNS acknowledged that there was no physician's order to monitor urinary output and indicated that nurses only document urinary output if there is a physician's order. This lack of documentation and monitoring raises concerns about the adequacy of care provided to residents with indwelling catheters.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure each resident's medication regimen was free from a medication error rate of 5% or greater. During a medication administration task, surveyors observed 25 opportunities for errors, with 2 errors resulting in an 8% error rate. Resident ID #86, who has a physician's order for Eliquis 5 mg every morning and night for septic pulmonary embolism, did not receive the morning dose as ordered. Similarly, Resident ID #7, who has a physician's order for Fluticasone Proprionate nasal suspension for nasal congestion, did not receive the medication as ordered. Both errors were acknowledged by Registered Nurse, Staff O, during surveyor interviews. The Director of Nursing Services confirmed that residents are expected to receive their medications as ordered and could not provide evidence that the facility ensured a medication error rate below 5%.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in care. Resident ID #66, who was readmitted with a stage 4 pressure ulcer and other conditions, had a physician's order for heel boots to be applied every shift. However, during multiple surveyor observations, the heel boots were not in place, despite being documented as applied in the Treatment Administration Record (TAR). Licensed Practical Nurse, Staff E, confirmed the heel boots were not in place and could not explain the discrepancy in the documentation. Additionally, one of the heel boots was missing from the resident's room. Resident ID #105, who was readmitted with varicose veins, open wounds, and lymphedema, had a physician's order to off-load wounds as tolerated. Surveyor observations revealed that the wounds were not off-loaded during multiple checks, even though the TAR indicated that the off-loading had been completed. Licensed Practical Nurse, Staff F, was unable to explain the inaccurate documentation. The Director of Nursing Services also could not provide an explanation for the staff's inaccurate record-keeping.
Failure to Provide SNFABN Forms to Residents
Penalty
Summary
The facility failed to provide proper notice to residents and/or their representatives regarding changes in Medicare Part A coverage, specifically related to the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) of Non-coverage Form. This deficiency was identified for two residents who were discharged from Medicare Part A services but remained in the facility. For Resident ID #111, the last covered day of Medicare Part A services was on 10/20/2023, and for Resident ID #143, it was on 11/3/2023. In both cases, there was no evidence that the SNFABN form was issued to the residents or their representatives, as required by Medicare guidelines. During interviews with facility staff, including the Minimum Data Set Coordinator and the Director of Nursing Services, it was confirmed that the SNFABN forms should have been issued to the residents. However, the staff were unable to provide any evidence that these forms were completed and given to the residents or their representatives. This failure to provide the necessary notices constitutes a deficiency in the facility's compliance with Medicare requirements for informing residents about potential financial liabilities for services not covered by Medicare.
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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