Cedar Haven Operations Llc Dba Lake Forrest Health
Inspection history, citations, penalties and survey trends for this long-term care facility in Smithfield, Rhode Island.
- Location
- 180 Log Road, Smithfield, Rhode Island 02917
- CMS Provider Number
- 415049
- Inspections on file
- 45
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 18 (2 serious)
Citation history
Health deficiencies cited at Cedar Haven Operations Llc Dba Lake Forrest Health during CMS and state inspections, most recent first.
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 altered mental status and seizures was not treated with dignity when a nursing assistant commented on their odor in their presence and later covered the resident's consented video monitoring device with a pillow. The DON confirmed these actions and could not provide evidence that the resident's rights to respect and electronic monitoring were upheld.
A resident with a gastrostomy, requiring Enhanced Barrier Precautions (EBP), received care from two nursing assistants who did not wear gowns as mandated by facility policy. Despite clear signage and staff awareness of EBP requirements, video evidence and staff interviews confirmed non-compliance with gown use during high-contact care activities. The DON could not provide documentation of an effective infection control program related to EBP for this resident.
A resident with multiple chronic conditions was administered a combination of medications, including Schedule II narcotics, intended for another resident after a CMT became distracted and confused medication cups. The medications had been pre-poured by an RN and given to the CMT to administer, which was outside the CMT's scope of practice. The resident became unresponsive and required emergency intervention and hospital transfer due to the medication error.
A resident with multiple chronic conditions was hospitalized after being mistakenly given a combination of antipsychotics, antidiabetic agents, benzodiazepines, and narcotics intended for another resident. The error occurred when a medication aide, distracted during medication pass, administered the wrong medications, including Schedule II controlled substances, resulting in the resident becoming unresponsive and requiring emergency interventions such as Narcan and hospitalization.
A nursing assistant made inappropriate sexual comments and exposed her chest to a resident with a history of mental health conditions but intact cognition. The incident was witnessed and reported by another NA, and both staff statements confirmed the event. The facility failed to provide evidence that the resident was protected from sexual abuse as required by policy.
A facility failed to follow a physician's orders for a resident with multiple health conditions, including congestive heart failure and COPD, by not obtaining weekly weights as directed. The deficiency was confirmed during an interview with the DON, who acknowledged the oversight.
A resident with HIV did not receive their prescribed medication, BIKTARVY, for four days due to an alleged agreement for the family to provide it, which was undocumented. Staff interviews confirmed the missed doses and lack of documentation, while the resident was aware of the importance of not missing the medication.
A resident with a gastrostomy tube was administered Isosource 1.5 Cal nutritional formula without a current physician's order, following the discontinuation of the order. Despite the lack of a valid order, the resident continued to receive the formula at 60 ml/hour, as confirmed by an LPN and the DON, who could not provide an explanation for the discontinuation.
A resident receiving nutrition via a G-tube was documented as receiving Nutren 2.0 and Two Cal HN 2.0 formulas, despite these not being available in the facility. Instead, the resident was administered Isosource 1.5 Cal. Staff interviews confirmed the inaccurate documentation and unavailability of the prescribed formulas.
A resident with a history of atherosclerosis and dementia experienced ongoing left leg pain and swelling. Despite a physician's order for an orthopedic consult, the resident refused the initial appointment, and the facility failed to reschedule it or address the pain effectively. Staff interviews revealed a lack of communication and follow-up, leading to the resident's continued discomfort.
The facility failed to maintain effective infection control, particularly in using Enhanced Barrier Precautions (EBP) and Covid-19 protocols. Staff did not consistently wear required PPE during high-contact care for residents needing EBP, and Covid-19 positive residents were not adequately protected as staff entered rooms without proper PPE and neglected hand hygiene. Interviews confirmed these lapses, indicating systemic issues in infection control practices.
The facility failed to provide care in accordance with professional standards for two residents. One resident, with a hip fracture, did not have a physician's order for toe touch weight bearing, leading to independent ambulation without restrictions. Another resident, with schizoaffective disorder, refused an antipsychotic injection twice, and staff failed to notify the provider or reschedule the medication. Staff interviews revealed a lack of awareness and communication regarding these care needs.
A resident with opioid dependence did not receive Lorazepam as ordered due to a failure in medication delivery and administration. Despite the medication being available in the facility's pyxis machine, the resident missed five doses. Staff interviews revealed that the medication should have been administered immediately, and the delay was not communicated to the appropriate personnel.
A resident with moderately impaired cognition and a history of falls was not provided with the required frequent safety checks, leading to a fall and hip fracture. Despite the care plan indicating the need for checks every 20-30 minutes, staff were unaware of this requirement, and there was no documentation to ensure compliance.
A resident with severe cognitive impairment entered another resident's room and physically assaulted them by grabbing their neck. Staff intervened to separate the residents, but the incident was reported as a failure to protect residents from abuse. Both residents have severe cognitive impairments, and the event was acknowledged by the facility's Director of Nursing Services.
Two residents experienced communication difficulties with a non-English speaking NA, impacting their ability to convey needs for ADLs. Both residents have intact cognition and require extensive assistance. The NA, who works the 3:00 PM to 11:00 PM shift, confirmed her inability to understand English, and the facility's administrator acknowledged this language barrier.
The facility failed to support resident choice in shower preferences for two residents. One resident, with intact cognition, reported not receiving showers as per their preference, and records showed no evidence of showers in the last 30 days. Another resident, with severely impaired cognition, reported only two showers in six months, with no evidence of showers in the last 30 days. The administrator could not provide evidence of compliance with the residents' preferences.
A resident with dementia and cognitive impairment eloped from a facility due to inadequate supervision and incomplete wandering risk assessment. Despite being at moderate risk for wandering, necessary interventions were not implemented. The resident, requiring supervision while smoking, was not monitored outside the smoking area, leading to their unsupervised exit. They were found by police in the roadway, confused and wearing heavy clothing, highlighting the facility's failure to ensure safety.
A resident with severe cognitive impairment was sexually abused by another resident with a history of inappropriate behavior. Despite previous incidents, the facility failed to update the care plan or notify the physician, leading to the resident being left unsupervised and vulnerable. Staff interviews revealed that the resident was often left unsupervised in the victim's room, contributing to the incident.
The facility failed to provide a consistent activities program for residents on the North B Unit, resulting in residents being left alone or wandering without engagement. Scheduled activities were not held, and there was no activities calendar available. Residents with Alzheimer's and other conditions were observed without participation in group or one-on-one activities, despite care plans indicating the need for structured engagement. Staff interviews revealed a lack of awareness and insufficient staffing for activities, particularly on weekends.
The facility failed to provide adequate care and timely interventions for two residents. One resident experienced severe edema and wound issues without proper notification or intervention, leading to a hospital admission for DVT and paracentesis. Another resident had unresponsive incidents that were not reported to the provider, resulting in a lack of necessary assessments and interventions. The facility also failed to obtain an admission weight and address a fall incident appropriately.
The facility failed to maintain a sanitary and comfortable environment, with surveyors observing stained and odorous bathrooms across all units. Staff interviews confirmed the persistent issues, and a change in cleaning products was noted as ineffective. Additionally, the flooring and carpets were in poor condition, requiring repair or replacement.
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 Honor Resident Dignity and Electronic Monitoring Rights
Penalty
Summary
A deficiency was identified when a nursing assistant (NA) failed to treat a resident with respect and dignity during care. The NA was observed and acknowledged making a comment about the resident's odor within earshot of the resident, who was able to understand and respond to yes/no questions. This action was captured on video surveillance footage provided by the resident's family. The facility's policies require that all residents be treated with respect and dignity, and the Director of Nursing Services (DNS) was unable to provide evidence that the resident was treated appropriately in this instance. Additionally, the same NA was observed on video covering the resident's electronic monitoring camera with a pillow, despite the resident having provided consent for video surveillance and appropriate signage being posted in the room. The DNS confirmed that the NA covered the camera and could not provide evidence that the resident's right to use electronic monitoring equipment was respected. The resident involved had diagnoses including altered mental status and seizures and had been admitted to the facility several months prior to the incident.
Failure to Follow Enhanced Barrier Precautions for Resident with Gastrostomy
Penalty
Summary
The facility failed to maintain an infection prevention and control program as required, specifically regarding the use of Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy. Facility policy mandates the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices or wounds. Despite signage indicating EBP requirements in the resident's room, video surveillance footage on two separate dates showed that two nursing assistants provided morning care to the resident without wearing gowns, as required by policy. Interviews with the Infection Preventionist and the nursing assistants confirmed that the resident had been on EBP since admission and that staff were aware of the requirement to wear gowns and gloves during care. However, both nursing assistants acknowledged not wearing gowns during the observed care episodes. The Director of Nursing Services was unable to provide evidence that the facility maintained an infection control program to prevent the spread of infection related to EBP for this resident.
Significant Medication Error Due to Incompetent Medication Administration and Protocol Breaches
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets to provide safe nursing and related services, as evidenced by a significant medication error involving a resident. A Certified Medication Technician (CMT) administered a cup of medications intended for another resident, which included multiple drugs such as Schedule II narcotics, anticonvulsants, antidiabetics, and other medications. This error occurred after the CMT became distracted during the medication pass, placed the wrong medication cup in the cart, and subsequently administered it to the wrong resident. The medications had been pre-poured by a Registered Nurse (RN), who also provided the narcotics to the CMT for administration, despite this being outside the CMT's scope of practice. The resident who received the incorrect medications had a medical history including heart failure, intellectual disabilities, and chronic obstructive pulmonary disease. Following administration of the wrong medications, the resident was found lethargic, unresponsive, and with pinpoint pupils. Emergency intervention was required, including the administration of Narcan and transfer to the hospital, where the resident received activated charcoal for overdose treatment. Interviews with staff revealed that the RN had signed out and prepared narcotics for one resident and gave them to the CMT to administer, which was not in accordance with scope-of-practice regulations. The CMT acknowledged being distracted and administering the wrong medications, including narcotics, to the resident. The Director of Nursing confirmed that the RN should not have delegated the administration of narcotics to the CMT and that medications should not have been pre-poured and left in the medication cart. These failures in following established medication administration protocols and scope-of-practice requirements resulted in a significant medication error and placed the resident in immediate jeopardy.
Resident Hospitalized After Receiving Another Resident's Medications
Penalty
Summary
A significant medication error occurred when a certified medication staff member, while distracted during the morning medication pass, administered a set of medications intended for one resident to another resident. The medications included antipsychotics, antidiabetic agents, benzodiazepines, narcotics, and other drugs, some of which were Schedule II controlled substances that medication aides are not permitted to administer according to state regulations. The error was facilitated by the nurse providing narcotics to the medication aide to administer, and by the medication aide pre-pouring and leaving the medications unattended in the medication cart. The resident who received the incorrect medications had a medical history including heart failure, intellectual disabilities, and chronic obstructive pulmonary disease. After receiving the wrong medications, the resident was found lethargic, unresponsive, and with pinpoint pupils. Emergency interventions were required, including the administration of two doses of Narcan, EMS transport, and subsequent hospitalization. The resident also received activated charcoal in the emergency room due to the overdose. Facility records and staff interviews confirmed that the medication aide signed off the administration of the medications in the wrong resident's Medication Administration Record (MAR). The nurse involved acknowledged giving the narcotics to the medication aide, and both staff members confirmed the sequence of events that led to the error. The Director of Nursing Services also acknowledged that the resident received another resident's medications, resulting in the need for emergency medical treatment and hospital admission for overdose.
Failure to Protect Resident from Sexual Abuse by Nursing Assistant
Penalty
Summary
A nursing assistant (NA), identified as Staff C, engaged in inappropriate conduct with a resident who had a history of bipolar disorder, anxiety, and adjustment disorder, but was assessed as cognitively intact with a BIMS score of 15. Staff C entered the resident's room, initiated conversation by complimenting the resident's appearance, and then lifted her own shirt to expose her chest while wearing a sports bra, stating that she too was 'sexy.' This incident was directly witnessed by another NA, Staff D, who immediately reported the behavior to the Director of Nursing Services (DNS). The facility's abuse prohibition policy defines sexual abuse as any non-consensual sexual contact, including unwanted intimate touching or exposure, regardless of the resident's cognitive status. The resident involved did not recall the incident during a surveyor interview, but statements from both Staff C and Staff D confirmed the inappropriate exposure and comments. The facility's investigation documented the sequence of events and the resident's reaction, but there was no evidence provided that the facility ensured the resident was kept free from sexual abuse as required by policy.
Failure to Follow Physician's Orders for Resident Weights
Penalty
Summary
The facility failed to meet professional standards of quality by not following a physician's orders for a resident who was readmitted with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, and acute kidney failure. The physician had ordered weekly weights to be obtained starting on March 8, 2025. However, a review of the resident's electronic medical record and progress notes revealed that the weights were not recorded on March 8, 2025, or March 15, 2025, as ordered. This deficiency was identified during a surveyor interview with the Director of Nursing Services, who acknowledged that the weights were not completed as required.
Failure to Administer HIV Medication as Prescribed
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Bictegravir-Emtricitabine-Tenofovir (BIKTARVY), a medication prescribed for HIV treatment. The resident, who was admitted in March 2025 with diagnoses including HIV and dialysis dependence, did not receive the prescribed medication on four consecutive days. The Electronic Medication Administration Record (EMAR) for March 2025 showed no evidence of administration on the specified dates. Nursing progress notes indicated that the medication was expected to be brought in by the resident's family, and a filled prescription was available at the community pharmacy. Interviews with staff and the resident revealed that the medication was not administered due to an alleged agreement for the family to provide it, which was not documented. The resident was aware of the missed doses and had informed the facility of the importance of not missing the medication. Staff members, including the Registered Nurse, LPN, Administrator, and Director of Nursing Services, acknowledged the missed doses and the lack of evidence for the agreement. The Medical Director was informed of the initial unavailability but was unaware of the continued missed doses.
Failure to Follow Physician's Orders for G-tube Nutrition
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding the administration of nutrition via a gastrostomy tube (G-tube). The resident, who was admitted with diagnoses including protein-calorie malnutrition, dysphagia, and a gastrostomy tube, had a physician's order for Isosource 1.5 Cal nutritional formula to be administered four times a day, which was discontinued on December 23, 2024. However, the resident continued to receive the Isosource 1.5 Cal without a current physician's order on multiple occasions after the discontinue date. Surveyor observations and staff interviews revealed that the resident was administered Isosource 1.5 Cal at 60 ml/hour without a valid physician's order. Staff A, a Licensed Practical Nurse, confirmed the administration of the formula and was unable to provide evidence of a current physician's order. The Director of Nursing Services also acknowledged the lack of a physician's order and could not explain why the order was discontinued. This deficiency highlights a failure in following physician's orders and ensuring proper documentation for the resident's nutritional care.
Inaccurate Documentation of G-tube Nutrition Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident receiving nutrition via a gastrostomy tube. The resident was admitted with diagnoses including protein-calorie malnutrition, dysphagia, and a gastrostomy tube. Physician's orders were in place for Nutren 2.0 and Two Cal HN 2.0 formulas to be administered via the G-tube. However, the Medication Administration Record (MAR) inaccurately documented that these formulas were administered, despite their unavailability in the facility. During a surveyor observation, it was noted that the resident was being administered Isosource 1.5 Cal instead of the prescribed formulas. Staff interviews revealed that the facility did not have the Nutren 2.0 or Two Cal HN formulas available, and the resident had been receiving Isosource 1.5 Cal since admission. The Administrator and Director of Nursing Services acknowledged the discrepancy, confirming that the orders were signed off inaccurately and the prescribed formulas were not available at the facility prior to the observation.
Failure to Provide Timely Orthopedic Care
Penalty
Summary
The facility failed to ensure that a resident received timely treatment and care in accordance with professional standards of practice. The resident, who was admitted in July 2023 with diagnoses including atherosclerosis of bilateral legs and dementia, had a physician's order for an orthopedic consult due to chronic bilateral knee pain. Despite the resident's complaints of left leg pain and swelling, and a scheduled orthopedic appointment on December 4, 2023, the resident refused to attend the appointment. The facility did not reschedule the appointment or address the ongoing pain effectively, as evidenced by continued complaints of pain and swelling in the resident's left leg. Interviews with staff revealed a lack of communication and follow-up regarding the resident's condition. The LPN acknowledged the resident's pain regimen was ineffective, and the Nurse Practitioner was unaware of the resident's continued pain after the missed appointment. The Director of Nursing Services confirmed the resident's refusal to attend the initial appointment but did not ensure a rescheduled appointment until it was brought to their attention by the surveyor. This lack of timely intervention and communication resulted in the resident experiencing ongoing pain and discomfort.
Infection Control Deficiencies in PPE Usage and Covid-19 Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for several residents. Surveyor observations revealed that staff did not adhere to the required use of personal protective equipment (PPE) such as gowns and gloves during high-contact care activities for residents with conditions necessitating EBP. For instance, a nursing assistant was observed transferring a resident with wounds without wearing a gown, despite the resident being on EBP. Additionally, there was a lack of EBP signage and PPE supplies at the doors of residents who required such precautions, indicating a systemic issue in implementing EBP protocols. Further deficiencies were noted in the facility's handling of Covid-19 precautions. Residents who tested positive for Covid-19 were not adequately protected as staff failed to don the necessary PPE, including gowns, gloves, and face shields, when entering their rooms. This was observed when a certified medication technician entered a Covid-19 positive resident's room without the required PPE and failed to perform hand hygiene, subsequently delivering trays to other residents. Similarly, laundry staff entered another Covid-19 positive resident's room without PPE and did not perform hand hygiene, citing language barriers as a reason for not understanding the posted precautions. Interviews with staff, including the Infection Preventionist and the Director of Nursing Services, confirmed that the expected protocols were not followed. They acknowledged that staff should have worn the appropriate PPE and performed hand hygiene as per the facility's signage and infection control policies. The lack of adherence to these protocols highlights significant lapses in the facility's infection prevention and control measures, particularly in the context of EBP and Covid-19 precautions.
Failure to Ensure Professional Standards of Care
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. For Resident ID #21, who was admitted with mantle cell lymphoma and anxiety disorder, the facility did not have a physician's order for toe touch weight bearing status after the resident suffered a fall resulting in a left hip fracture. Despite recommendations from the hospital and physical therapy for toe touch weight bearing, the resident was found to be ambulating independently, and staff were unaware of the weight bearing restrictions. This lack of communication and documentation led to the resident not receiving the appropriate care as per the hospital's recommendations. For Resident ID #35, who was admitted with schizoaffective disorder and dementia, the facility failed to follow its medication administration policy. The resident had a physician's order for Invega Sustenna, an antipsychotic medication, to be administered every 28 days. However, the resident refused the medication on two occasions, and there was no evidence that the staff notified the provider or attempted to reschedule the injection. The staff's failure to communicate the refusals to the provider or nursing management resulted in the resident not receiving the necessary medication as prescribed. Interviews with staff, including nursing assistants, LPNs, and the Director of Nursing Services, revealed a lack of awareness and communication regarding the residents' care needs and medication refusals. The Nurse Practitioner also confirmed that she was not informed of the hospital's recommendations or the medication refusals, which would have prompted her to take further action. These deficiencies highlight a breakdown in communication and adherence to professional standards of practice within the facility.
Failure to Administer Lorazepam as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Lorazepam. The resident, who was admitted with a diagnosis including opioid dependence, had a physician's order for Lorazepam to be administered twice daily for seven days. However, the medication was not administered as ordered on two occasions due to it not being delivered by the pharmacy. This resulted in the resident missing five doses of Lorazepam. Interviews with staff revealed that the medication was available in the facility's pyxis machine, an automated medication dispensing system, and most nurses had access to it. The Licensed Practical Nurse who entered the order and the Director of Nursing Services both acknowledged that the medication should have been administered immediately. The Nurse Practitioner also expected the medication to be started on the day it was ordered and to be notified if it was unavailable. Despite these expectations, the resident did not receive the medication until four days after it was ordered.
Failure to Provide Adequate Supervision for Resident at Risk of Falls
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for a resident who required frequent safety checks. The resident, admitted in June 2024 with diagnoses including mantle cell lymphoma and anxiety disorder, was found to have moderately impaired cognition. On 9/18/2024, the resident fell in their room and was sent to the emergency room, later returning to the facility with a left hip fracture. The resident's care plan indicated a risk for falls due to weakness and pain, with an intervention for frequent safety checks due to impulsivity. However, staff interviews revealed that the resident was not on frequent safety checks as required by the care plan. The Director of Nursing Services acknowledged the need for frequent safety checks every 20-30 minutes but could not explain why staff were unaware of this requirement. Additionally, there was no documentation to confirm that safety checks were being conducted, and the Director of Nursing Services did not expect staff to document these checks. This lack of awareness and documentation contributed to the failure in providing the necessary supervision to prevent the resident's fall and subsequent injury.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving two residents. Resident ID #2, who has severe cognitive impairment and a history of dementia with psychotic disturbance, entered the room of Resident ID #1, who also has severe cognitive impairment and a history of Alzheimer's disease. Despite being told to leave, Resident ID #2 grabbed Resident ID #1 by the neck. Staff members intervened to separate the residents, but the incident highlights a failure to prevent physical abuse. The incident was reported to the Rhode Island Department of Health, and staff statements corroborated the event. A housekeeper witnessed the altercation and called for assistance, while a nursing assistant and a nurse responded to separate the residents. The Director of Nursing Services acknowledged the occurrence of the incident. Despite the intervention, the facility's inability to prevent the altercation constitutes a deficiency in protecting residents from abuse.
Language Barrier in Resident Care
Penalty
Summary
The facility failed to provide an environment that promotes the maintenance or enhancement of the quality of life for residents whose primary language is not the dominant language of the staff providing care. Specifically, two residents, identified as Resident ID #1 and Resident ID #2, were unable to effectively communicate their needs to a Nursing Assistant (NA) on the 3:00 PM to 11:00 PM shift, who does not speak English. Resident ID #1, who has intact cognition and is totally dependent on staff for transfers and requires extensive assistance for activities of daily living (ADLs), expressed difficulty in communicating with the NA due to the language barrier. Similarly, Resident ID #2, who also has intact cognition and requires extensive assistance for ADLs, reported that the NA regularly assigned to their room attempts to communicate using signs and gestures, which is ineffective. During interviews, the NA, identified as Staff A, confirmed her inability to understand English, especially when spoken quickly, and was only able to respond to questions when asked in French. The facility's administrator acknowledged that Staff A is a full-time employee who does not speak English, which further substantiates the communication barrier experienced by the residents.
Failure to Support Resident Choice in Shower Preferences
Penalty
Summary
The facility failed to promote and facilitate resident self-determination through support of resident choice regarding weekly showers for two residents. Resident ID #1, who was readmitted in June 2023 with diagnoses including dysphagia, contractures, and anarthria, was found to have an intact cognition with a BIMS score of 15 out of 15. Despite being totally dependent on staff for transfers and requiring extensive assistance for bathing, the resident reported not receiving morning care or showers as per their preference. The resident's care plan indicated that showers were very important, yet there was no evidence of showers being provided in the last 30 days. Similarly, Resident ID #3, readmitted in September 2020 with diagnoses of muscle weakness, unsteadiness, and major depressive disorder, had a severely impaired cognition with a BIMS score of 6 out of 15. Despite this, the resident was interviewable and reported having only two showers in the last six months. The facility's records failed to show evidence of showers being provided in the last 30 days, and the administrator could not provide evidence of compliance with the residents' shower preferences.
Resident Elopement Due to Inadequate Supervision and Incomplete Risk Assessment
Penalty
Summary
The facility failed to ensure adequate supervision and interventions for a resident identified as a moderate risk for wandering, leading to an elopement incident. The resident, who was admitted with diagnoses including dementia, Wernicke's encephalopathy, and traumatic brain injury, was assessed to have moderately impaired cognition. Despite being at a moderate risk for wandering, the facility did not implement necessary interventions such as the application of a wanderguard or frequent checks. Additionally, a subsequent wandering risk assessment was incomplete, failing to accurately assess the resident's cognitive orientation and medication use, which would have maintained the resident's moderate risk status. On the day of the incident, the resident was last seen by staff at approximately 9:00 AM sitting outside the facility. The resident, who required supervision while smoking due to cognitive loss, was not adequately monitored when not in the designated smoking area. The smoking attendant confirmed that she did not supervise residents outside the smoking area, and the Assistant Director of Nursing stated that residents assessed as wander risks should be accompanied to and from the smoking area. However, the facility did not ensure this protocol was followed, resulting in the resident eloping from the facility. The resident was found by a police officer after being reported by a community member as confused and laying in the roadway. The resident was transported to the hospital, where it was noted that they were wearing unseasonably heavy clothing and were unsure of their location or what had happened. The facility's failure to provide adequate supervision and complete the wandering risk assessment accurately placed the resident at risk for harm, as evidenced by the unsupervised exit and subsequent discovery on the roadway.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident involving two residents with severely impaired cognition. Resident ID #1, who has aphasia, Alzheimer's disease, and dementia, was found in a vulnerable situation with Resident ID #2, who has major depressive disorder with severe psychotic disorder, anxiety disorder, and insomnia. Both residents reside on a secured unit and have a BIMS score of 0, indicating severely impaired cognition. The incident occurred when a nursing assistant observed Resident ID #2 stroking Resident ID #1's genitalia, with Resident ID #1 unable to consent due to cognitive impairment. Prior to the incident, there were multiple instances of inappropriate behavior by Resident ID #2 that were not adequately addressed by the facility. These included an attempt to kiss the Assistant Director of Nursing Services and previous incidents of inappropriate behavior towards staff and other residents. Despite these behaviors, there was no evidence that the physician was notified or that Resident ID #2's care plan was updated to include interventions to mitigate or monitor such behaviors. The facility's inaction in addressing Resident ID #2's inappropriate behaviors and failure to update the care plan contributed to the incident of sexual abuse. Staff interviews revealed that Resident ID #2 was often left unsupervised in Resident ID #1's room, despite previous combative behavior when asked to leave. The lack of intervention and monitoring placed Resident ID #1 and other cognitively impaired residents at risk for harm.
Failure to Provide Adequate Activities Program
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the needs and preferences of residents on the North B Unit, a secured/locked unit. The surveyor's observations and interviews revealed that scheduled activities were not consistently held, and there was no evidence of an activities calendar being available or posted for residents. The Director of Recreation provided a monthly activities calendar upon request, but several scheduled activities, such as Afternoon Devotionals and Friday Flicks, did not occur as planned. Resident ID #7, who has Alzheimer's disease, major depressive disorder, and anxiety disorder, was observed multiple times sitting alone or falling asleep in the activity/dining room without participating in any group or one-on-one activities. The resident's care plan included structured activities like walking outside and reading, but these were not offered. Similarly, Resident ID #4, with dementia and anxiety disorder, was observed alone in their room without engagement in activities, despite their care plan emphasizing the importance of socialization and exercise. Resident ID #6, with Alzheimer's disease and vascular dementia, was also observed alone or wandering without participating in activities, despite their care plan's focus on simple, structured activities. Additionally, Resident ID #5, with Alzheimer's disease and major depressive disorder, lacked a social care plan and was observed pacing and standing alone. Interviews with staff revealed a lack of awareness of the activities calendar and insufficient staffing to provide activities, particularly on weekends, leading to residents wandering more frequently.
Failure to Provide Adequate Care and Timely Interventions
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards for two residents, leading to significant deficiencies. Resident ID #1, who was on hospice care with chronic pain and pancreatic cancer, experienced fluctuating and severe edema in the lower extremities, which was not adequately addressed by the facility staff. Despite assessments indicating 4+ pitting edema, no interventions or orders were implemented, and the provider was not notified of the resident's increasing edema and pain. The resident eventually requested to go to the hospital, where an acute DVT was diagnosed. Additionally, the resident's abdominal girth was not measured as ordered due to the unavailability of a measuring tape, and the resident was admitted to the hospital for a paracentesis procedure. Further deficiencies were noted in the management of Resident ID #1's wounds. An open area on the resident's right lower extremity was identified but not reported to the provider, and no new interventions or orders were implemented. The wound nurse was not made aware of the new wounds until several days later, and the resident experienced significant pain during wound care. Additionally, the resident experienced a fall, but there was no evidence of an assessment or notification to the physician, nor were any interventions put in place to prevent future falls. The facility also failed to obtain an admission weight for the resident as ordered. Resident ID #2, who had dementia and type two diabetes mellitus, experienced two unresponsive incidents that were not properly addressed. On both occasions, the provider was not notified, and no interventions were implemented. The Nurse Practitioner was unaware of these incidents and indicated that an assessment and lab orders would have been conducted if informed. The facility staff failed to alert the on-call provider when the Nurse Practitioner did not return the call, leading to a lack of appropriate response to the resident's change in condition.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility was found to have failed in maintaining a safe, sanitary, and comfortable environment for residents, staff, and the public across all four units observed. Surveyor observations revealed that multiple bathrooms, including those in resident rooms, staff areas, and public spaces, had heavy accumulations of yellow and brown stains in the toilet bowls, accompanied by a strong odor of urine. These conditions were corroborated by interviews with various staff members, including registered nurses, nursing assistants, and housekeepers, who confirmed the persistent presence of stains and odors over several months. The housekeepers noted a change in cleaning products from Clorox bleach to Ecolab 73 Disinfecting Acid Bathroom Cleaner, which they reported as ineffective in removing the stains. Additionally, the surveyors observed that the flooring throughout the facility, including resident rooms, hallways, and office areas, was scuffed, and the carpets were heavily stained. The facility's Administrator acknowledged the need for repair or replacement of the flooring. These findings were based on community complaints submitted to the Rhode Island Department of Health, which alleged issues with cleanliness and sanitation, contributing to an uncomfortable environment. The facility's leadership, including the Director of Nursing Services and the Administrator, acknowledged the deficiencies observed by the surveyors.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
