Crystal Lake Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pascoag, Rhode Island.
- Location
- 999 South Main Street, Pascoag, Rhode Island 02859
- CMS Provider Number
- 415099
- Inspections on file
- 30
- Latest survey
- April 17, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Crystal Lake Rehabilitation And Care Center during CMS and state inspections, most recent first.
During a kitchen inspection, surveyors observed black and pink residue inside an ice machine, a dark brown liquid leaking from a kitchen appliance, and a buildup of grease-like residue on exhaust hoods, all of which were acknowledged by the FSD as needing cleaning.
A facility-wide assessment was not properly documented, as it lacked input from direct care staff, residents, and their representatives, and did not include a plan for recruitment and retention of direct care staff. The assessment was completed only by administrative and department leaders, without broader participation as required.
Several MDS assessments were found to be inaccurate, with two residents who actively used tobacco products incorrectly documented as non-users, and three residents with side rails for bed mobility mistakenly coded as having restraints. Staff interviews and record reviews confirmed these errors, and facility leadership acknowledged the inaccurate coding.
A resident with a history of failure to thrive and repeated falls had a provider order for a neurology consult due to worsening tremors and swallowing difficulties. Despite ongoing symptoms and documentation of the order, staff interviews and record reviews confirmed that the neurology appointment was never scheduled, attended, or declined, and the resident reported still needing the consult.
A resident with type II diabetes did not receive insulin lispro as ordered on multiple occasions, and there was no documentation that the provider was notified when the medication was withheld. Staff interviews confirmed that there were no parameters to hold the insulin and that the provider should have been informed, but this did not occur.
The facility did not provide the required Notice of Medicare Non-Coverage (NOMNC) to three residents who were discharged from Medicare Part A stays with benefit days remaining. Record review and staff interviews confirmed that the NOMNC forms were not issued, and staff were unaware of the requirement to provide the notice even when residents agreed with discharge.
A CMT impersonated a nurse and administered schedule 2 narcotics to residents, which is outside her scope of practice. The incident was discovered when she attempted to impersonate a nurse again, leading to an investigation that revealed her actions on a previous shift. Staff interviews confirmed the misrepresentation and inappropriate medication handling.
The facility failed to follow physician's orders for blood sugar monitoring for eight residents with diabetes, as their blood sugar levels were not checked at the specified times. This deficiency was acknowledged by the DON and Clinical Consultant during a surveyor interview.
The facility failed to administer insulin as ordered to five residents with diabetes, as documented in the November MAR. The residents did not receive their prescribed insulin doses, and there was no evidence that the physician was informed of these missed doses. The Director of Nursing Services and the Clinical Consultant acknowledged the oversight during a surveyor interview.
A resident with a history of seizures was readmitted to an LTC facility but did not receive prescribed medications due to a failure in transcribing admission orders. The DNS had indicated she would complete the admission, but it was not done, leading to the resident missing doses of critical medications, including anti-seizure drugs. This resulted in the resident experiencing seizures and being sent to the hospital. Additionally, an antibiotic dose was missed due to a miscommunication about the start date.
A resident with severe cognitive impairment eloped from a facility due to inadequate supervision and failure to update care plans. Despite being at risk for elopement, the resident's care plan was not updated after an initial incident, and a wander guard was not implemented. The resident was later found in the road, unsupervised, highlighting significant lapses in supervision and policy adherence.
The facility failed to provide food prepared in a form designed to meet individual needs for residents requiring thickened fluids. Multiple residents with dysphagia were given fluids that were not thickened to the required consistency, and staff were unaware of the correct preparation methods. This placed the residents at risk for serious harm.
The facility failed to follow its bowel protocol for two residents and did not adhere to physician's orders for wound care for another resident. One resident experienced significant discomfort and expired due to a colonic ileus, while another went 12 days without a bowel movement. Additionally, wound care for a third resident did not follow prescribed treatments, and proper documentation was lacking.
The facility failed to ensure nourishing snacks were offered to residents outside of scheduled meal times, resulting in a 15 1/2 hour gap between the evening meal and breakfast. Residents expressed that bedtime snacks were not offered, and staff confirmed that no one was assigned to distribute snacks at night. The Registered Dietitian acknowledged that the snacks provided were not nourishing enough.
The facility failed to store food in accordance with professional standards, with unlabeled and undated food items, expired food, and a leaking sink pipe leading to an ant infestation. Additionally, the hot water dish machine exceeded sanitization temperature limits, and the kitchenette resident refrigerator was not maintained at a safe temperature.
The facility failed to provide the correct fluid consistency for two residents requiring pudding thick liquids, with staff unaware of the proper consistency. Additionally, 40 residents did not receive scheduled medications during a shift, and a resident with a foley catheter was observed with their genitals uncovered during a catheter flush, compromising their privacy.
The facility failed to provide an effective infection prevention and control program, particularly in the disinfection of glucometers and the proper use of PPE. Staff did not adhere to the facility's policy for cleaning glucometers and did not use the required PPE for residents on enhanced barrier precautions. The Infection Preventionist acknowledged these lapses, indicating systemic issues within the facility's infection control program.
The facility failed to establish an Infection Prevention and Control Program that includes an antibiotic stewardship program. Three residents were prescribed antibiotics without evidence of an antibiotic review process to determine if the antibiotics were still indicated or if adjustments should be made. The Infection Preventionist confirmed the absence of a review process.
The facility failed to provide the required 12 hours of annual in-service training for three nurse aides who had been employed for over a year. The Administrator acknowledged the lapse during an interview.
The facility failed to ensure accurate assessment for a resident who experienced a fall with major injury. The resident, readmitted with a subarachnoid hemorrhage, was found on the floor and later admitted to the hospital with a brain bleed. The MDS inaccurately documented the fall, and the Infection Preventionist could not provide evidence of accurate documentation, revealing that MDS assessments are done remotely without an on-site coordinator.
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their medical, nursing, and psychosocial needs. Despite multiple care areas being triggered in MDS assessments, no care plans were created or implemented, as acknowledged by the Infection Preventionist and Administrator during surveyor interviews.
The facility failed to provide appropriate treatment and services for three residents diagnosed with UTIs. Despite care plans and physician's orders to encourage fluid intake, there was no evidence of fluid intake monitoring or documentation of fluid encouragement for the residents while on antibiotics. Interviews with the Medical Director and Infection Preventionist confirmed the facility did not follow its policy related to intake documentation and fluid encouragement.
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets, impacting resident safety and well-being. Observations revealed issues in wound care, dressing changes, glucometer cleaning, foley catheter management, and suctioning. Additionally, three nursing assistants did not receive required in-services and education on critical topics.
A resident with prostate cancer and depression requested a change in antidepressant medication and a geriatric psychiatry consult. Despite the recommendation, there was no evidence that the consult was scheduled, offered, attended, or refused. Interviews with staff confirmed the consult had not been obtained.
The facility failed to maintain a medication error rate below 5%, with 10 errors observed out of 35 opportunities, resulting in an error rate of 28.57%. Errors included late administration and incorrect medications given to five residents, as confirmed by staff interviews and record reviews.
The facility failed to ensure timely administration of medications to 40 residents, resulting in significant medication errors. Observations and record reviews revealed that critical medications for conditions such as dementia, COPD, heart failure, and hypertension were not administered as ordered. Interviews with the Medical Director and Administrator confirmed the deficiency, with no explanation provided for the lapse.
The facility failed to provide adequate privacy for a resident during foley catheter care, exposing the resident's genitals to the hallway and roommate. Staff did not close the door or privacy curtain as expected.
The facility failed to follow a physician's order for double portions for a resident with dementia. Observations revealed the resident did not receive double portions during meals, and staff interviews confirmed the oversight. The resident expressed a need for more food due to their tall stature.
A facility failed to ensure a resident with a stage 2 pressure ulcer received necessary treatment and services, as the prescribed zinc and medihoney treatment was not administered for a specified period. Interviews with medical staff confirmed the treatment should have been in place, but the facility could not provide evidence of compliance.
The facility failed to maintain proper respiratory care equipment for two residents using oxygen and one resident requiring suctioning. Observations revealed discolored and outdated oxygen tubing and improperly maintained suction equipment, with staff unsure of cleaning protocols. The Director of Nursing Services acknowledged these deficiencies.
The facility failed to store and label drugs and biologicals in accordance with professional principles. Observations revealed undated and improperly stored medications, including Ativan Intensol and insulin pens, and expired Vancomycin solution. Staff acknowledged the deficiencies, and the Administrator could not provide evidence of compliance.
The facility failed to maintain accurate medical records for a resident with significant health issues, including missing documentation of lung sounds and suctioning as per physician's orders. Both the Infection Preventionist and Medical Director confirmed the expectation for proper documentation, which was not met.
The facility failed to update and post the results of the most recent surveys in a readily accessible area. Staff and residents were unaware of the survey results binder's location, and the binder had not been updated to include approximately 13 recent surveys.
A resident with severe cognitive impairment and a history of exit-seeking behaviors successfully eloped from the facility twice. Despite having a care plan that included a wander guard, the resident repeatedly removed the device, and staff failed to implement new interventions. The resident was found outside on two occasions, once by a neighbor who witnessed the resident fall twice. The facility did not ensure adequate supervision or the proper use of the wander guard, placing the resident at risk for harm.
The facility failed to protect the rights of five residents by posting their photographs on social media without obtaining consent. Residents with dementia, PTSD, and other conditions had their photos posted online without permission, causing distress to family members. The Activities Director and Administrator admitted that consents were not obtained.
The facility failed to document and communicate the assistance needs for five residents requiring help with transfers and ambulation. The necessary information was not included in the residents' records or the NA assignment sheets, leading to a deficiency in providing required services.
A resident admitted with CMV and kidney transplant status did not receive correct dosages of Gabapentin and Tamsulosin for 7 days due to transcription errors. Additionally, the resident did not receive Magnesium oxide and Valganciclovir for 7 days. The facility also failed to monitor the resident's AV fistula and double lumen power port, as confirmed by the resident's physician and the DON.
The facility failed to provide appropriate UTI and catheter care for three residents. One resident developed sepsis due to inadequate monitoring and lack of antibiotic administration. Another resident's temperature was not consistently checked as per the care plan, and a third resident had no care plan for their Foley catheter, with inconsistent urine output monitoring.
A resident's mail was opened without permission, causing significant distress. The Administrator's inappropriate response escalated the situation, leading to police intervention. The facility failed to protect the resident's privacy and well-being, demonstrating poor resource management.
A resident with psoriasis and other conditions had been complaining about skin issues for months and was promised a dermatology consult, which was never arranged. Despite multiple orders and discussions, the consult was not scheduled, leading to ongoing skin issues and an emergency room visit where the resident expressed concerns about mistreatment.
A resident's mail was opened before delivery, leading to an upset resident who felt their privacy was invaded. The Administrator's dismissive and provocative response escalated the situation, resulting in police involvement. The resident, with moderately impaired cognition, was not treated with respect and dignity, as required by regulations.
A resident with moderately impaired cognition became upset when their mail was opened without consent. The Administrator responded inappropriately, stating it was her right to open the mail and called the police when the resident became agitated. Staff interviews revealed this was not the first occurrence, and the Administrator admitted to opening the resident's mail in the past.
A visually impaired resident was moved from a private room with a bathroom to a semi-private room without a bathroom without their permission or notification. Despite the resident's cognitive intactness and independence in self-care tasks, the facility did not consider the resident's familiarity with their environment due to their visual impairment. This led to the resident experiencing distress, behavioral outbursts, and ultimately being admitted to a geri-psych unit. The involuntary room change and subsequent emotional distress highlight the failure to individualize the physical environment based on the resident's specific needs and preferences, resulting in significant psychosocial harm.
The facility failed to provide written notice of its bed-hold policy to a resident or their representative prior to the resident's transfer to the hospital. The resident had multiple diagnoses, including major depressive disorder and visual impairments. The Administrator and DON could not provide evidence of the notice during the surveyor interview.
A resident, who is legally blind, was moved to a new room without permission and subsequently tripped over boxes, resulting in sore knees. The facility failed to conduct a post-fall assessment as required by their policy, and staff were unaware of the fall until the surveyor's visit.
A resident's legal representative requested a copy of the resident's medical records but received only 10 pages, which were incomplete. Despite further attempts to obtain the missing records, the facility did not respond, and the Administrator directed the complainant to contact vendors for additional records. The issue was resolved six months later after a surveyor's intervention.
Deficient Kitchen Sanitation and Equipment Cleanliness
Penalty
Summary
Surveyor observations during an initial tour of the main kitchen, in the presence of the Food Service Director (FSD), revealed several deficiencies in food storage, preparation, and cleanliness. Specifically, a white component inside the ice machine was found to have black and pink matter that could be wiped away with a paper towel. A Kitchen Aid appliance was observed covered with a clear plastic bag, with a dark brown liquid leaking from a seam onto both the bag and the appliance. Additionally, there was an accumulation of a grease-like residue on the exhaust hoods above the stove and griddle, with a sticker indicating the hoods had last been cleaned several months prior. The FSD acknowledged these findings and confirmed that these areas should have been cleaned.
Failure to Complete Comprehensive Facility-Wide Assessment and Staffing Plan
Penalty
Summary
The facility failed to document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment, last updated on 3/10/2025, included input from the Administrator, Director of Nursing Services, Director of Environmental Services, and Medical Director, but lacked involvement from direct care staff such as Registered Nurses, LPNs, Nursing Assistants, or their representatives. Additionally, there was no evidence that input from residents, their representatives, or family members was solicited or considered in the assessment process. Further review revealed that the facility assessment did not include a plan to maximize recruitment and retention of direct care staff. During an interview, the Administrator confirmed that neither direct care staff nor residents, family, or their representatives were involved in the assessment, and acknowledged the absence of a recruitment and retention plan as required by regulation.
Inaccurate MDS Assessments for Tobacco Use and Restraint Coding
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of several residents regarding tobacco use and the use of restraints. For two residents with documented tobacco use, care plans and smoking evaluations indicated active use of tobacco products, including vaping, during the relevant assessment periods. However, their MDS assessments incorrectly documented that they did not use tobacco products during the 7-day look-back period. This discrepancy was identified through record review and staff interviews, which confirmed the residents' ongoing tobacco use. Additionally, for three residents with physician orders for the use of 1/4 top side rails as enablers for bed mobility and transfers, the MDS assessments inaccurately coded the use of these side rails as restraints. Staff interviews clarified that the side rails were not used as restraints and did not meet the definition of a physical restraint as outlined in the RAI Manual. The MDS Coordinator and the Director of Nursing Services acknowledged that these MDS assessments were coded in error, resulting in inaccurate documentation of the residents' status.
Failure to Schedule Ordered Neurology Consult for Resident with Tremors
Penalty
Summary
A deficiency occurred when a resident with diagnoses including adult failure to thrive and repeated falls was admitted and subsequently had a physician's order placed for a neurology consult due to increased tremors and trouble swallowing. Documentation showed that the order for the neurology consult was made, and the resident continued to experience symptoms such as upper extremity tremors and difficulty drinking. Despite these ongoing symptoms and the documented order, there was no evidence in the resident's record, progress notes, or the facility's transport calendar that a neurology consult was ever scheduled, attended, or declined by the resident. Interviews with facility staff, including an LPN and the DON, confirmed that the appointment was neither scheduled nor tracked, and the staff member responsible for appointments was unaware of the order. The resident also confirmed during an interview that they had not declined the appointment and continued to experience tremors, expressing the need for the consult. The facility was unable to provide any documentation that the neurology consult was arranged as ordered by the provider.
Failure to Administer Insulin as Ordered and Notify Provider
Penalty
Summary
The facility failed to ensure that insulin administration services met professional standards of practice for one resident with type II diabetes. Physician orders specified that insulin lispro was to be administered subcutaneously at specific times each day, with no parameters provided for withholding the medication. Record review showed that on three separate occasions, the insulin was not administered as ordered, despite documented blood sugar levels. There was no evidence in the records that the provider was notified when the insulin was not given on these dates. Interviews with staff confirmed that the insulin should have been administered as ordered and that any deviation, such as holding the medication, should have been reported to the provider. The LPN acknowledged the absence of parameters to hold the insulin, and the DON was unable to provide evidence that the medication was administered as ordered. The nurse practitioner also stated that she expected to be notified if the medication was held. These findings indicate that the facility did not follow physician orders or notify the provider when the insulin was not administered.
Failure to Provide Required Notice of Medicare Non-Coverage to Discharged Residents
Penalty
Summary
The facility failed to provide required notice to residents and/or their representatives regarding changes in Medicare Part A coverage, specifically the delivery of the Notice of Medicare Non-Coverage (NOMNC) form. For three residents who were discharged from a Medicare-covered Part A stay with benefit days remaining, there was no evidence in the records that the NOMNC form was issued prior to discharge. The last covered day of Medicare Part A services and the discharge date for each resident were reviewed, and in each case, documentation of the NOMNC form was absent. Interviews with facility staff confirmed the deficiency. The Minimum Data Set Coordinator acknowledged that the NOMNC forms were not provided to the affected residents and stated she was unaware that the form was required even when the resident agreed with the discharge. The Administrator was also unable to provide evidence that the NOMNC forms had been issued for the residents in question.
Unlicensed Staff Impersonation and Medication Mismanagement
Penalty
Summary
The facility failed to ensure that staff were licensed, certified, or registered in accordance with applicable state laws, as evidenced by the actions of a Certified Medication Technician (CMT), referred to as Staff A. On November 1, 2024, Staff A impersonated a licensed nurse and performed duties outside her scope of practice, including conducting a narcotic count and administering schedule 2 narcotics, such as oxycodone, to residents. This incident was reported to the Rhode Island Department of Health, and it was discovered that Staff A attempted to impersonate a nurse again on November 3, 2024, but was stopped by a Nursing Supervisor, Staff B, who identified her as a CMT. Interviews with various staff members, including the Director of Nursing Services (DNS), Licensed Practical Nurse (LPN) Staff C, and Registered Nurses (RN) Staff D and E, revealed that Staff A was scheduled to work as a CMT but misrepresented herself as a nurse. Staff C noted that Staff A was unsure of how to complete a narcotic count, and Staff E acknowledged that Staff A appeared unsure of her actions. The DNS and Clinical Consultant confirmed that Staff A inaccurately portrayed herself as a nurse and acknowledged that administering schedule 2 narcotics is beyond the scope of practice for a CMT.
Failure to Follow Physician's Orders for Blood Sugar Monitoring
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by not following physician's orders for blood sugar monitoring. This deficiency was identified for eight residents, all of whom had diabetes mellitus and required regular blood sugar checks as per their physician's orders. The orders included specific instructions to check blood sugar levels at designated times and to notify the physician if the levels were outside specified ranges. For Resident ID #1, the physician's order required blood sugar checks before meals and at bedtime, with specific instructions to contact the physician if the blood sugar was less than 70 or greater than 300. However, the November 2024 Medication Administration Record (MAR) showed that the resident's blood sugar was not checked at the specified times on 11/1/2024. Similar deficiencies were noted for Residents ID #4, #6, #7, #8, #9, #10, and #11, where blood sugar checks were either missed or not conducted as ordered, particularly on the evening of 11/1/2024. The Director of Nursing Services and the Clinical Consultant acknowledged during a surveyor interview that the blood sugar checks for these residents were not performed as ordered. This failure to adhere to physician's orders for blood sugar monitoring represents a significant lapse in the facility's obligation to provide care in accordance with professional standards, potentially impacting the health and safety of the residents involved.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of insulin. Five residents with diabetes mellitus did not receive their prescribed insulin doses on a specific date. The residents involved were admitted or readmitted to the facility with a diagnosis of diabetes mellitus, and their care plans included interventions to administer diabetic medications as ordered. However, the November Medication Administration Record (MAR) showed that these residents did not receive their scheduled insulin doses as prescribed. Additionally, there was no evidence that the facility informed the physician about the missed insulin doses for these residents. During an interview with the Director of Nursing Services and the Clinical Consultant, it was acknowledged that the insulin doses were not administered as required. This oversight affected the residents' management of their diabetes, as they were at risk for unstable blood sugars due to the missed medication.
Failure to Transcribe and Administer Medications
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, particularly in the transcription of admission orders. The resident, who had a history of seizures and anxiety disorder, was readmitted to the facility from the hospital with specific medication orders. However, the medications were not transcribed into the electronic medication record, resulting in the resident not receiving any of the prescribed medications, including anti-seizure medications, from the afternoon of one day until the following afternoon. This lapse led to the resident experiencing seizure-like activity and being sent back to the hospital for evaluation. The issue arose when the resident was readmitted to the facility, and the admission process was not completed. The Director of Nursing Services (DNS) had indicated to a Registered Nurse (RN) that she would complete the admission orders, but this was not done. Consequently, the resident's medications were not administered as per the hospital discharge paperwork. The oversight was discovered when a Nurse Practitioner (NP) noticed the absence of scheduled medications and issued STAT orders to administer the necessary medications. Additionally, the resident did not receive a dose of Cefdinir, an antibiotic for a urinary tract infection, during a subsequent shift. The RN on duty acknowledged the omission, stating that the DNS instructed her to change the start date of the medication, which the DNS later denied. This series of events highlights the facility's failure to adhere to proper medication administration protocols, resulting in significant medication errors for the resident.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and interventions to prevent an elopement incident involving a resident with severe cognitive impairment. The resident, who was readmitted with diagnoses including dementia and cognitive communication deficit, was assessed as having severely impaired cognition. Despite this, an incomplete elopement assessment initially indicated minimal risk, and a care plan was not deemed necessary. However, a baseline care plan was initiated, indicating the resident was at risk for elopement, with interventions to redirect from exits and engage in diversional activities. On a specific date, the resident was found outside on a patio near a gate, raising questions about the need for a wander guard. The facility did not complete an investigation into how the resident accessed the patio and failed to implement a wander guard as per policy. The care plan was not updated following this incident, and quarterly elopement evaluations were not completed as required. Subsequently, the resident was found in the road by a community member, indicating a failure in supervision and intervention. Interviews revealed that staff had observed the resident attempting to exit the facility the day before the elopement but did not report it or update the care plan. The Director of Nursing Services acknowledged the failure to assess and update the care plan after the attempted elopement and the lack of quarterly evaluations. These failures resulted in the resident exiting the facility unsupervised, posing a significant risk to their safety.
Failure to Provide Properly Thickened Fluids
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet individual needs for residents requiring thickened fluids. Resident ID #19, who had diagnoses including dysphagia, aspiration pneumonia, and stroke, was observed being given fluids that were not thickened to the pudding consistency as ordered. Staff members were unaware of the correct consistency and how to achieve it, leading to the resident being served fluids that were not safe for their condition. The Director of Nursing Services also acknowledged the lack of knowledge and appropriate products to achieve the required consistency in the facility. Resident ID #16, with diagnoses including dysphagia and traumatic brain injury, was also not provided with fluids thickened to the pudding consistency as ordered. During an observation, a staff member incorrectly prepared the fluids, resulting in them not reaching the required thickness. The staff member was unaware of the correct preparation method, and the fluids were not served at the appropriate temperature or consistency, posing a risk to the resident. Additionally, Resident ID #12 and Resident ID #100, both requiring nectar thick liquids, were observed being given thin fluids with straws, contrary to their physician's orders. Staff members and a family member were not properly educated on how to prepare the fluids to the correct consistency. This lack of proper preparation and education led to residents being served fluids that did not meet their individual needs, placing them at risk for serious harm.
Failure to Follow Bowel Protocol and Wound Care Orders
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. For Resident ID #47, the facility did not follow its bowel protocol despite the resident not having a bowel movement for 5 days or 14 consecutive shifts. The resident experienced significant discomfort, including pain in multiple areas and vomiting, and eventually expired. The facility staff did not administer Milk of Magnesia or a Bisacodyl suppository as required by the protocol, and the resident was found to have a colonic ileus at the time of death. Interviews with staff revealed a lack of awareness and adherence to the bowel protocol. Resident ID #39 also did not receive appropriate care according to the facility's bowel protocol. The resident did not have a bowel movement for 12 days or 36 consecutive shifts, yet the protocol was not initiated. The resident reported no pain or discomfort but was unaware that they could request medication for constipation. Staff interviews confirmed that the bowel protocol should have been started on day 3 without a bowel movement, but it was not followed. For Resident ID #4, the facility failed to follow the physician's orders for wound care. The resident had multiple wounds on the right lower extremity, but the wound care provided did not adhere to the prescribed treatment. The nurse did not use the correct wound cleanser, did not apply the required ointment, and did not moisten the wound dressing as ordered. Additionally, the nurse failed to document the wounds properly, including their descriptions and measurements, and did not develop a care plan for the wounds. Staff interviews confirmed these deficiencies in wound care documentation and adherence to physician orders.
Failure to Provide Nourishing Bedtime Snacks
Penalty
Summary
The facility failed to ensure nourishing snacks were offered to residents who desired them outside of scheduled meal service times. The review of meal service times revealed a 15 1/2 hour gap between the evening meal and breakfast the following day. During the survey, it was observed that breakfast was served no earlier than 8:10 AM. The menu review for weeks 3 and 4 showed that the snacks provided at night were minimal, consisting of items like a half cup of orange drink and one cookie. Residents expressed during a council meeting and individual interviews that bedtime snacks were not offered, and they had to request them if they wanted any. Several residents indicated a preference for being offered snacks, and some even mentioned that they used to receive snacks when a designated person delivered them after dinner, but this practice had ceased. Staff interviews confirmed that no one was assigned to pass out snacks at night, and residents had to go to the nurses' station if they wanted a snack, which was not feasible for all residents. The Registered Dietitian acknowledged that the snacks provided were not nourishing enough for the long time span between meals. The deficiency was identified for five residents who were reviewed for bedtime snacks. Record reviews for these residents showed no evidence that bedtime snacks were documented as received. The Infection Preventionist and the Registered Dietitian both acknowledged the inadequacy of the current snack offerings and the lack of a designated person to distribute snacks at night. The Registered Dietitian specifically noted that a nourishing snack should include two food groups, which was not met by the current offerings of a cookie and a half cup of lemonade. This failure to provide adequate and nourishing snacks outside of scheduled meal times led to the deficiency noted in the report.
Food Storage and Safety Deficiencies
Penalty
Summary
The facility failed to store food in accordance with professional standards of food service safety. During an initial tour of the main kitchen, surveyors observed several deficiencies, including unlabeled and undated food items in the walk-in refrigerator, such as sliced zucchini and squash, and shredded yellow and white cheese. Additionally, expired food items were found in the dry storage room, including bags of pearled barley and a can of sausage gravy. The Food Service Director (FSD) acknowledged these issues and was unable to provide evidence that the food items were properly labeled, dated, or free from contamination. Furthermore, the dish room and wash room had a leaking three-bay sink pipe and missing ceramic tiles, which had led to an ant infestation. The FSD had reported these issues to maintenance, but repairs had not yet been completed at the time of the surveyor's visit. The facility also failed to maintain proper sanitization temperatures for the hot water dish machine, with final rinse cycle temperatures exceeding the maximum allowed 194 degrees Fahrenheit on multiple occasions. The FSD was unaware of the temperature limit and had not taken corrective action until informed by the surveyor. Additionally, the kitchenette resident refrigerator was found to have a thermometer reading of 48 degrees Fahrenheit, with multiple recorded instances of temperatures over 40 degrees Fahrenheit. There was no evidence that the supervisor on duty was notified of these unsafe temperatures, as required by the facility's protocol. The FSD was unable to provide evidence that the refrigerator was maintained at a safe temperature.
Deficiencies in Fluid Consistency, Medication Administration, and Privacy
Penalty
Summary
The facility failed to administer care in a manner that effectively and efficiently used its resources to maintain the highest practicable well-being of its residents. Specifically, two residents requiring pudding thick liquids were not provided with the correct consistency. Staff members, including LPNs and the Director of Nursing Services, were observed preparing fluids incorrectly, either to nectar thick or honey thick consistency instead of the ordered pudding thick consistency. The staff was unaware of the correct consistency and how to achieve it, leading to improper administration of fluids to residents with dysphagia and other related conditions. Additionally, a resident with a foley catheter was observed with their genitals uncovered during a catheter flush, compromising their privacy and dignity. Furthermore, the facility failed to administer scheduled medications to 40 residents during a specific shift. The Medication Compliance Report indicated that these residents did not receive their medications, and the Infection Preventionist and Administrator were unable to explain the cause of this lapse. These deficiencies highlight significant issues in medication administration and adherence to physician orders, impacting the overall care and well-being of the residents.
Infection Control and PPE Deficiencies
Penalty
Summary
The facility failed to provide an effective infection prevention and control program, particularly in the disinfection of glucometers and the proper use of Personal Protective Equipment (PPE). During a survey, it was observed that a Registered Nurse did not clean the glucometer after each use as required by the facility's policy. The nurse admitted that the correct wipes were not available, and the Director of Nursing Services confirmed that the correct wipes were in the basement but were not being used. Another nurse was observed using an alcohol wipe instead of the required bleach wipe to clean the glucometer, indicating a lack of adherence to the facility's infection control policy. The facility also failed to ensure proper PPE usage for residents requiring enhanced barrier precautions. One resident with a urinary catheter was observed receiving care from staff who only wore gloves, despite signage indicating that both gloves and gowns were required. The staff involved admitted to not being aware of the required PPE. Another resident with a multi-drug resistant organism (MDRO) was observed being boosted in bed by a nurse assistant who did not wear a gown, as required by the enhanced barrier precautions. The Infection Preventionist acknowledged that the staff should have been wearing the appropriate PPE and that the facility did not maintain an effective infection control program. The deficiencies highlight a lack of adherence to infection control policies and procedures, as well as inadequate staff training and awareness regarding the proper use of PPE and disinfection protocols. These lapses were observed in multiple instances and involved different staff members, indicating systemic issues within the facility's infection prevention and control program.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an Infection Prevention and Control Program (IPCP) that includes an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use. This deficiency was identified for three residents who were prescribed antibiotics. Resident ID #26 was prescribed Cipro for a urinary tract infection, Resident ID #29 was prescribed Augmentin for a urinary tract infection, and Resident ID #39 was prescribed Cipro. In all three cases, there was no evidence that the facility implemented an antibiotic review process, also known as an antibiotic time-out, to determine if the antibiotic was still indicated or if adjustments should be made. During an interview, the Infection Preventionist revealed that there was no process in place for reviewing residents receiving antibiotics or obtaining laboratory or diagnostic testing to determine if the antibiotic was still indicated or if adjustments should be made. This lack of a review process is contrary to the guidelines set forth by the Centers for Disease Control and Prevention, which recommend standardizing practices for evaluating and communicating clinical signs and symptoms, optimizing diagnostic testing, and implementing an antibiotic review process to reassess the need for and choice of antibiotics.
Failure to Provide Required In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to provide a minimum of 12 hours per year of in-service training to ensure the continuing competence of nurse aides. Record review of three nurse aides, identified as Staff H, I, and J, revealed that they had all been employed at the facility for over a year. However, there was no evidence that they had received the required annual 12-hour in-service training. During an interview, the Administrator acknowledged that the annual training had not been provided for these staff members.
Inaccurate Resident Assessment for Falls with Major Injury
Penalty
Summary
The facility failed to ensure that the assessment accurately reflected the resident's status for a resident assessed for falls with major injury. Resident ID #19 was readmitted to the facility in December 2023 with a diagnosis including subarachnoid hemorrhage. On 11/14/2023, the resident was found on the floor in their room, complaining of headache, nausea, change in vision, and lethargy. The resident was assessed by a nurse, and 911 was called for emergency transfer to the hospital. The resident was admitted to the hospital with a brain bleed. However, the Minimum Data Assessment (MDS) completed on 3/25/2024 inaccurately documented one fall with no injuries and no falls with major injury. During a surveyor interview, the Infection Preventionist was unable to provide evidence that the resident's assessment was accurately documented, revealing that MDS assessments are being completed remotely and that the facility does not have an MDS coordinator on-site.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their medical, nursing, and psychosocial needs. Resident ID #4, admitted with osteomyelitis and peripheral vascular disease, had multiple care areas triggered in the MDS assessment, including cognitive loss, activities of daily living, falls, and pressure ulcers. Despite these triggers and known concerns such as wounds and falls, no care plan was developed or implemented. This was acknowledged by the Infection Preventionist during a surveyor interview. Similarly, Resident ID #29, admitted with chronic obstructive pulmonary disease and repeated falls, had care areas triggered in the admission MDS assessment, including activities of daily living, urinary incontinence, falls, pressure ulcers, and psychotropic medication use. However, no care plan was created or implemented for these areas, as confirmed by the Infection Preventionist during a surveyor interview. Resident ID #100, admitted with cerebral infarction, dependence on renal dialysis, and type II diabetes mellitus, also lacked a comprehensive care plan. The resident had orders for renal dialysis and sliding scale insulin, but the care plan did not include interventions to mitigate risks associated with dialysis and diabetes. This deficiency was acknowledged by both the Infection Preventionist and the Administrator during a surveyor interview. The lack of comprehensive care plans for these residents indicates a failure to meet their medical, nursing, and psychosocial needs as identified in their comprehensive assessments.
Failure to Provide Appropriate UTI Treatment and Services
Penalty
Summary
The facility failed to provide appropriate treatment and services for three residents diagnosed with urinary tract infections (UTIs). Resident ID #26, admitted with diagnoses including diabetes and chronic obstructive pulmonary disease, had a care plan and physician's orders to encourage fluid intake while on Cipro for a UTI. However, there was no evidence of fluid intake monitoring or documentation of fluid encouragement from 4/19/2024 through 4/24/2024, with only one recorded instance on 4/25/2024. Similarly, Resident ID #29, admitted with chronic obstructive pulmonary disease and requiring assistance with personal care, had a care plan and physician's orders to encourage fluids every shift while on Augmentin for a UTI. There was no evidence of intake monitoring or documentation of fluid encouragement from 4/27/2024 through 5/1/2024. Resident ID #39, admitted with diagnoses including malignant neoplasm of the prostate and depression, had a care plan to monitor and document fluid intake and encourage fluids every shift while on Cipro for a UTI. However, there was no evidence of fluid intake monitoring or documentation of fluid encouragement for the entire month of March 2024. Interviews with the Medical Director and Infection Preventionist confirmed that the facility did not follow its policy related to intake documentation and fluid encouragement for residents with UTIs, as expected by the facility's standards.
Failure to Ensure Nursing Staff Competencies and Required Education
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being of each resident. This deficiency was identified for three nurses and three nursing assistants. Surveyor observations from 4/25/2024 through 5/1/2024 revealed concerns related to wound care, clean dressing changes, glucometer cleaning and disinfection, foley catheter management, and suctioning. Record reviews failed to show evidence that competencies in these areas were completed for the registered nurse and two licensed practical nurses involved. Interviews with the Infection Preventionist and the Administrator confirmed the lack of completed competencies for these staff members. Additionally, a review of personnel files indicated that three nursing assistants did not receive required in-services and education on various critical topics, including resident rights, person-centered care, basic nursing skills, infection control, and compliance and ethics. The Administrator confirmed that these competencies and educational requirements should have been completed annually and as needed but were not. This failure to ensure proper training and competencies directly impacts the quality of care provided to residents.
Failure to Provide Necessary Behavioral Health Care
Penalty
Summary
The facility failed to ensure that a resident received the necessary behavioral health care and services. Resident ID #39, admitted in July 2023 with diagnoses including prostate cancer and depression, was noted in a hospice visit on January 4, 2024, to be experiencing a depressed mood and requested a change in antidepressant medication. The hospice note recommended a geriatric psychiatry consult to address the resident's symptoms of depression. However, there was no evidence that such a consult was scheduled, offered, attended, or refused by the resident. Interviews with the Infection Preventionist and the Medical Director confirmed that the expected geriatric psychiatry consult had not been obtained.
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 the survey, 35 opportunities for error were observed, resulting in 10 errors and an error rate of 28.57%. The errors involved five residents, including late administration of medications and incorrect medications being given. For example, Resident ID #19 received Propranolol one hour after the scheduled time, and Resident ID #45 received Gabapentin four hours late. Resident ID #99 did not receive a Nicotine patch, was given Senna instead of Senna Plus, and received Quetiapine 1.5 hours late. Resident ID #20 received multiple medications 2.5 hours late, and Resident ID #29 received Pramipexole 1.5 hours late. The surveyor's observations and record reviews revealed that the facility did not adhere to the 5 rights of medication administration, as outlined in Mosby's Drug Guide. The errors were confirmed through staff interviews, where it was acknowledged that medications were not administered within the scheduled timeframes. The facility administrator also confirmed that residents were expected to receive their medications as ordered and within the scheduled timeframe but could not provide evidence that the facility ensured a medication error rate below 5%.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as observed during a survey on 4/26/2024. The surveyor's observation, record review, and staff interviews revealed that 40 out of 48 residents did not receive their prescribed medications within the required time frame. According to Mosby's Drug Guide, medications should be administered within 30 minutes of the scheduled time, but this standard was not met for numerous residents on the specified date. The medications missed included critical treatments for conditions such as dementia, COPD, heart failure, hypertension, diabetes, and major depressive disorder, among others. During the surveyor's observation at approximately 10:00 AM, it was noted that the timeliness of medication distribution and administration was a significant concern. The Administration Compliance Report dated 4/26/2024 detailed the specific medications that were not administered to each resident as ordered by their physicians. For instance, Resident ID #1, who has multiple diagnoses including dementia and COPD, did not receive several medications such as Azithromycin, Buspirone, Diltiazem, and Metformin, among others. Similar patterns of missed medications were observed for other residents, each with their own critical health conditions and prescribed treatments. Interviews with the Medical Director and the Administrator further confirmed the deficiency. The Medical Director was informed by staff at approximately 7:00 PM on 4/26/2024 about the missed medications and spent about 1.5 hours reviewing the situation with the staff. The Administrator acknowledged the issue but was unable to provide an explanation for why the medications were not administered. This widespread failure to administer medications as ordered represents a significant lapse in the facility's duty to provide proper care to its residents.
Failure to Provide Privacy During Foley Catheter Care
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not providing adequate privacy during foley catheter care. Resident ID #33, who was admitted with diagnoses including urinary retention and low back pain, had a physician's order for a foley catheter to be flushed every shift. During a surveyor observation, the resident was seen with the door open while an LPN and an RN were flushing and changing the resident's foley catheter, exposing the resident's genitals to the hallway and the roommate. Additionally, the Administrator did not close the door to offer privacy when providing a chair to the surveyor. The Infection Preventionist confirmed that staff are expected to close the door and privacy curtain before providing care.
Failure to Follow Physician's Order for Double Portions
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not following a physician's order for double portions. The resident, who was admitted in October 2023 with a diagnosis of dementia, had a physician's order dated February 29, 2024, for double portions. However, surveyor observations on April 26, 2024, April 30, 2024, and May 1, 2024, revealed that the resident did not receive double portions during meals. Interviews with the Rehabilitation Director and the Infection Preventionist confirmed that the resident's meal slip did not indicate double portions, and it was acknowledged that staff failed to follow the physician's order. The resident expressed a desire for double portions, noting their tall stature and need for more food.
Failure to Provide Necessary Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing. The resident, who was readmitted to the facility in January 2023 with diagnoses including the need for assistance with personal care and dementia, had a sacral wound with a treatment order to apply zinc and medihoney daily and as needed. However, a review of the April 2024 Medication Administration Record revealed that the treatment was not in place from April 14, 2024, through April 25, 2024. Interviews with the Wound Physician, Infection Preventionist, and Medical Director confirmed that the resident should have been receiving the prescribed wound treatment. The facility's staff, including the Administrator and Infection Preventionist, were unable to provide evidence that the resident was provided with the necessary treatment and services during the specified period. This failure to follow the treatment order was inconsistent with professional standards of practice and did not promote healing or prevent infection for the resident's stage 2 pressure ulcer.
Failure to Maintain Proper Respiratory Care Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents using oxygen and one resident requiring suctioning. For Resident ID #19, who was readmitted with diagnoses including dysphagia, aspiration pneumonia, and stroke, the facility did not maintain proper suction equipment hygiene. The suction canister and tubing were observed to contain multi-colored secretions with floating sediment, and staff were unsure of the last usage or cleaning time. There was no evidence of a policy or procedure for changing, cleaning, or replacing the suction equipment, as confirmed by the Administrator and Infection Preventionist during interviews. For Resident ID #1, who had chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia, the oxygen tubing was found to be discolored and dated several months prior, contrary to the facility's policy of weekly replacement. Similarly, Resident ID #29, who required continuous oxygen, had undated tubing, and there was no evidence that the tubing was changed weekly as per the facility policy. The Director of Nursing Services acknowledged these deficiencies during surveyor interviews.
Failure to Properly Store and Label Medications
Penalty
Summary
The facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles. During a surveyor observation of a nursing cart, it was found that there were three bottles of atropine 1% eye drops that were open and undated, one bottle of Ativan Intensol that was labeled to be refrigerated but was stored unrefrigerated, one Lantus Insulin Pen that was 13 days beyond its use-by date, and one Lispro Insulin Pen that was open and undated. Staff A acknowledged that these medications should have been dated when opened and discarded after the use-by date, and that the Ativan Intensol solution should have been refrigerated and discarded if not stored properly. Additionally, during a surveyor observation of the medication storage room, it was found that there was one bottle of Ativan Intensol solution that was open and undated, one bottle of Vancomycin solution with a use-by date that had passed, and multiple electronic devices stored under the sink. Staff A acknowledged that medications should be dated when opened and discarded after the use-by date, and that nothing should be stored under the sink. The Administrator was unable to provide evidence that the facility stores drugs and biologicals in accordance with currently accepted professional principles.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain accurate medical records for a resident with significant health issues, including dysphagia, aspiration pneumonia, and a stroke. Despite a physician's order to document lung sounds every shift, the nurse's notes from 4/1/2024 through 4/30/2024 showed 84 out of 90 instances where this documentation was missing. The Infection Preventionist and Medical Director both confirmed that the expectation was for nurses to document lung sounds per the physician's order, but this was not done consistently. Additionally, the facility did not accurately document the use of suctioning for the same resident. Although the resident required frequent suctioning, the Treatment Administration Record (TAR) did not reflect instances of suctioning on 4/20/2024, 4/25/2024, and 4/29/2024, despite progress notes indicating that suctioning occurred on those dates. The Infection Preventionist acknowledged that the resident required daily suctioning and that this was not properly documented. The Medical Director also confirmed that PRN orders should be documented, and she was unaware of the resident's frequent need for suctioning.
Failure to Update and Post Survey Results
Penalty
Summary
The facility failed to update and post the results of the most recent surveys conducted by Federal or State Surveyors in a readily accessible area for residents, staff, and the general public. During an interview, the Infection Preventionist was unsure of the location of the survey results binder. Multiple residents were also unaware of the binder's existence or location. The Administrator revealed that the binder had been stored in a closet and not updated to include approximately 13 recent surveys. The last entry in the binder was from a survey conducted in January 2024.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure that Resident ID #1 received adequate supervision to prevent elopement. The resident, who had severe cognitive impairment and was at risk for elopement, was found outside the facility on two separate occasions. Despite having a care plan that included the use of a wander guard, the resident repeatedly removed or hid the device, and staff failed to implement new interventions to address this behavior. On 3/9/2024, the resident was found outside lying on the ground and was sent to the hospital for evaluation. On 3/29/2024, the resident was again found outside, this time by a neighbor who witnessed the resident fall twice and assisted them back to the facility. In both instances, the resident was not wearing the wander guard as ordered, and no new interventions were put in place to prevent further elopements. The resident's medical history included Wernicke's encephalopathy, cognitive communication deficit, and abnormalities of gait and mobility. The resident required supervision with transfers and ambulation and had a history of exit-seeking behaviors. Despite these known risks, the facility did not ensure that the wander guard was consistently applied and functioning. Progress notes indicated multiple instances where the wander guard was found broken, removed, or missing, yet no effective measures were taken to ensure the resident's safety. Interviews with staff and the Director of Nursing Services confirmed that no new interventions were implemented following the resident's initial elopement on 3/9/2024. The resident continued to exhibit exit-seeking behaviors and successfully eloped again on 3/29/2024. The facility's failure to provide adequate supervision and ensure the proper use of the wander guard placed the resident at risk for harm, as evidenced by the two elopement incidents.
Unauthorized Posting of Resident Photos on Social Media
Penalty
Summary
The facility failed to protect and promote the rights of five residents by posting their photographs on social media without obtaining consent from the residents or their representatives. Resident ID #6, who had dementia and major depressive disorder, had their photograph posted on Facebook without consent, and the photo remained online even after the resident's death. Similarly, Resident ID #5, diagnosed with dementia and PTSD, had their photograph posted without consent and remained online for approximately 39 days. Resident ID #7, with a diagnosis of cerebral infarction, also had their photograph posted without consent, as did Resident ID #8, who had dementia and paranoid schizophrenia, with their photos remaining online for approximately 86 days. Resident ID #9, diagnosed with dementia and PTSD, had their photograph posted without consent and remained online for approximately 86 days as well. During interviews, the resident's family members expressed distress over the unauthorized posting of photographs. The Activities Director acknowledged that an outside company was used to post photos on the facility's Facebook page and admitted that consents were not obtained. The Administrator also confirmed that consents should have been obtained before posting any photographs but could not provide evidence that this was done. The facility's failure to secure consent before posting residents' photographs on social media constitutes a violation of the residents' rights to dignity, self-determination, and communication.
Failure to Document and Communicate Resident Assistance Needs
Penalty
Summary
The facility failed to provide necessary services to residents who were unable to perform activities of daily living (ADL) independently. This deficiency was identified for five residents who required assistance with transfers and ambulation. The records for these residents did not document the level of assistance required, and the nursing assistants' (NA) assignment sheets also lacked this critical information. The Director of Rehab confirmed that the nursing staff was verbally informed of the assistance each resident required, but this information was not documented in the electronic medical record accessible to the nursing staff. For Resident ID #1, the care plan indicated a risk for falls and required supervision with transfers and ambulation, but this was not documented in the resident's record or the NA assignment sheet. Similarly, Resident ID #2 required contact guard assistance (CGA) for transfers, but this was not reflected in the records. Resident ID #3 needed modified independence for transfers and CGA for ambulation, yet this information was missing from the records. Resident ID #4 required varying levels of assistance for transfers, ranging from maximum assistance to stand-by assistance, but this was not documented. Lastly, Resident ID #5 required minimal assistance for transfers, which was also not recorded in the resident's record or the NA assignment sheet. Interviews with the Director of Rehab, nursing staff, and NAs revealed that the transfer and ambulation status of residents were communicated verbally rather than documented. The Director of Nursing Services acknowledged that the residents' transfer and ambulation status were not documented in the medical record or on the NA assignment sheets. This lack of documentation and reliance on verbal communication led to a failure in providing the necessary services to ensure residents did not lose the ability to perform ADLs unless there was a medical reason.
Failure to Provide Accurate Medication and Monitor Medical Devices
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Resident ID #4, who was admitted in March 2024 with diagnoses including cytomegaloviral disease (CMV) and kidney transplant status, did not receive the correct dosages of Gabapentin and Tamsulosin for 7 days due to inaccurate transcription of medication orders. Additionally, the resident did not receive Magnesium oxide and Valganciclovir for 7 days because these medications were not ordered by the provider. The admitting nurse transcribed medications from a January 2024 hospitalization instead of the updated March 2024 hospital discharge After Visit Summary, leading to these discrepancies. Both the resident's physician and the Director of Nursing Services acknowledged the errors during surveyor interviews. Furthermore, the facility failed to monitor the resident's arteriovenous (AV) fistula and double lumen power port as required. The hospital discharge document indicated that the resident had an AV fistula and a double lumen power port, but the facility did not provide evidence of monitoring for patency, signs of infection, or other necessary assessments. Both the resident's physician and the Director of Nursing Services confirmed that the facility did not monitor these critical medical devices, which are essential for the resident's ongoing care and treatment.
Failure to Provide Appropriate UTI and Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services relative to urinary tract infections (UTI) and indwelling catheters for three residents. Resident ID #1 was admitted with a Foley catheter and experienced hematuria and discomfort. Despite a physician's order to initiate the UTI protocol, vital signs were not consistently monitored, and the prescribed antibiotic was not administered. The resident eventually developed sepsis and was transferred to the hospital. Additionally, there was no care plan developed for the Foley catheter, and fluid intake and urinary output were inadequately documented. Resident ID #2, who had a history of recurrent UTIs, had a care plan that included checking temperature every shift. However, the facility failed to consistently monitor the resident's temperature, missing 31 out of 114 opportunities. The resident continued to experience symptoms of a UTI, and there was no evidence that vital signs were obtained every shift for 72 hours as per the facility's UTI protocol. Resident ID #4 was readmitted to the facility with a UTI, sepsis, and a Foley catheter. There was no physician order for the Foley catheter until a month after readmission, and the order to measure urine output three times daily was not consistently followed. Additionally, there was no care plan developed for the Foley catheter. The Acting Director of Nursing Services acknowledged these deficiencies but could not provide an explanation for the lack of care plans and proper documentation.
Inappropriate Handling of Resident's Mail and Escalation by Administrator
Penalty
Summary
The facility failed to administer its resources effectively and efficiently to ensure the highest practicable physical, mental, and psychosocial well-being of a resident. The incident involved a resident whose mail was opened without permission, leading to significant distress. The resident, who has moderately impaired cognition due to parkinsonism and anxiety disorder, expressed anger and frustration over the invasion of privacy. The Administrator's response to the resident's complaint was inappropriate and escalated the situation, resulting in the police being called to deescalate the conflict. The police report and body camera footage indicated that the Administrator's behavior was antagonistic and unprofessional, further aggravating the resident's distress. Interviews with staff and the resident confirmed that the mail had been opened before being delivered, and this was not an isolated incident. The Administrator admitted to having opened the resident's mail in the past but was unsure who opened it on this occasion. Despite the Administrator's claims of not antagonizing the resident, the police report and body camera footage contradicted her statements. The Administrator's actions and the facility's failure to protect the resident's privacy and well-being demonstrate a lack of effective and efficient resource management, leading to a deficiency in the quality of care provided to the resident.
Failure to Arrange Dermatology Consult
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The resident, who has diagnoses including parkinsonism, anxiety disorder, and psoriasis vulgaris, had been complaining about skin issues for months and was promised a dermatology consult, which had not been arranged. The resident's medical records indicated multiple instances of skin issues, including scabs, dry skin, and eczema, and a dermatology consult was ordered by the physician in November. However, the consult was never scheduled, and the resident's condition persisted, leading to an emergency room visit where the resident expressed concerns about mistreatment and the lack of dermatology care. Interviews with staff and the resident's physician confirmed that the dermatology consult had not been completed despite multiple discussions and orders. The Interim Director of Nursing Services also confirmed that the resident had not been seen by a dermatologist and could not provide evidence that the physician's order was followed. This failure to arrange the necessary dermatology consult resulted in ongoing skin issues for the resident, highlighting a significant lapse in the facility's adherence to professional standards of care.
Failure to Treat Resident with Respect and Dignity
Penalty
Summary
The facility failed to treat a resident with respect and dignity, leading to a deficiency. The incident began when the resident's mail was opened before it was delivered to them, which upset the resident. The resident approached the Administrator to express their concern, but the Administrator responded dismissively, stating it was her right to open the mail. The situation escalated when the Administrator made a comment about wanting to provoke the resident to leave the facility, which led to the resident becoming very upset. The police were called, and the responding officer noted that the Administrator's behavior was inappropriate and escalated the situation further. The resident, who has moderately impaired cognition due to parkinsonism and anxiety disorder, felt their privacy was invaded. The police report and staff interviews corroborated the resident's account, indicating that the Administrator's actions were not respectful and did not promote the resident's quality of life. The Administrator was unable to provide evidence that the resident was treated with respect and dignity, as required by regulations.
Violation of Resident's Right to Mail Privacy
Penalty
Summary
The facility failed to respect a resident's right to personal privacy by opening their mail without consent. The incident involved a resident with moderately impaired cognition, diagnosed with parkinsonism and anxiety disorder, who became upset when they received their mail already opened. The resident reported the issue to the Administrator, who responded inappropriately by stating it was her right to open the mail and subsequently called the police when the resident became agitated. The police and rescue services were called to deescalate the situation, and the responding officer documented the Administrator's behavior on his body camera. Interviews with staff revealed that this was not the first time the resident's mail had been opened without permission. The Administrator admitted to having opened the resident's mail in the past but was unsure who opened it on this occasion. The facility's policy on resident rights states that residents have the right to receive mail unopened, yet the Administrator indicated that it was their policy to check the resident's mail before delivering it. The Administrator was unable to provide evidence that the resident's right to personal privacy regarding their mail was respected.
Failure to Accommodate Visually Impaired Resident's Needs and Preferences
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of Resident ID #1, a visually impaired resident, by moving them from a private room with a bathroom to a semi-private room without a bathroom without their permission or notification. Despite the resident's cognitive intactness and independence in self-care tasks, the facility did not consider the resident's familiarity with their environment due to their visual impairment. This led to the resident experiencing distress, behavioral outbursts, and ultimately being admitted to a geri-psych unit. The resident's refusal to change rooms, the involuntary move while they were hospitalized, and subsequent emotional distress and behavioral issues upon returning to the facility highlight the failure of the facility to individualize the physical environment based on the resident's specific needs and preferences. The lack of consideration for the resident's visual impairment and the impact of changing their living space without consent resulted in significant psychosocial harm to the resident, as evidenced by their behavioral outburst and subsequent admission to a geri-psych unit.
Failure to Provide Written Bed-Hold Policy Notice
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to the resident or the resident's representative prior to the resident's transfer to the hospital. The resident, who was admitted in March 2017 with diagnoses including major depressive disorder, visual hallucinations, low vision in the right eye, and blindness in the left eye, was transferred to the hospital on February 19, 2024. A review of the records did not reveal any evidence that a written bed-hold policy was provided to the resident or their representative. During an interview with the Administrator and the Director of Nursing Services, they were unable to provide evidence of such a notice being given.
Failure to Conduct Post-Fall Assessment
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The resident, who is legally blind and has been in the same room for five years, was moved to a new semi-private room without their permission. This move occurred while the resident was hospitalized, and upon returning, the resident tripped over boxes placed near their bed, resulting in sore knees. The facility did not conduct a post-fall assessment as required by their Falls Management policy. Interviews with staff revealed that the fall was not documented or communicated properly. The LPN who regularly cared for the resident was unaware of the fall, and the Medical Director only became aware of it during the surveyor's visit. The Administrator admitted to knowing about the fall but could not explain why the resident was not assessed for injuries. There was no documented evidence of a completed fall assessment, including vital signs, neurological signs, range of motion, and cognitive status, as per the facility's policy.
Incomplete Medical Records Provided to Resident's Representative
Penalty
Summary
A complaint was submitted to the Rhode Island Department of Health alleging that a resident's legal representative requested a copy of the resident's medical records in writing. The request was made on or about August 11, 2023, but the complainant received only approximately 10 pages, which they believed to be incomplete. Despite additional attempts to obtain the missing records through telephone calls and written requests in September 2023, the facility did not respond. The Administrator directed the complainant to contact facility-contracted vendors, including the pharmacy, for the remaining records. During a surveyor interview on February 26, 2024, the Administrator acknowledged that a complete medical record would contain physician notes, orders, care plans, and therapy documentation, which would be greater than 10 pages. The Administrator admitted to being aware of the request and personally presenting the incomplete file to the complainant. She also confirmed that she instructed the complainant to contact the vendors for additional records. After the surveyor brought the issue to the facility's attention, a complete copy of the resident's medical file, containing approximately 100 pages, was printed and made available to the resident's representative, six months after the initial request.
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.
