Golden Crest Nursing Centre
Inspection history, citations, penalties and survey trends for this long-term care facility in North Providence, Rhode Island.
- Location
- 100 Smithfield Road, North Providence, Rhode Island 02904
- CMS Provider Number
- 415029
- Inspections on file
- 32
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Golden Crest Nursing Centre during CMS and state inspections, most recent first.
The facility failed to develop and implement individualized care plans for residents, leading to inadequate assistance and care. Residents with specific needs, such as those with multiple sclerosis, dementia, and PTSD, did not have care plans that detailed the necessary level of assistance. Staff relied on verbal communication rather than comprehensive care plans, resulting in inconsistencies in resident care.
A resident with arthritis and muscle weakness was found to have five unopened lidocaine patches in their room without an assessment for self-administration. A physician's order required the application of a lidocaine patch daily, but there was no evidence of an assessment for self-administration. An LPN and the Assistant DON confirmed that the patches should have been stored in the medication cart.
The facility failed to properly store and label medications, as observed during a survey. Expired medications were found on the 2 East Medication Cart, and undated medications were discovered on the 2 [NAME] Medication Cart. Additionally, an undated multidose vial of Aplisol was found in the 2 East Medication Room. Staff acknowledged the oversight, and the DON expected medications to be dated and discarded appropriately.
A facility failed to maintain an infection prevention and control program for a resident using a BIPAP device. The resident, who had sleep apnea and acute respiratory failure, reported that their BIPAP machine was not cleaned by the facility. The manufacturer's instructions require daily cleaning of the device, but the facility did not have an order to clean the equipment, and the Director of Nursing Services could not provide evidence of cleaning.
A resident with GERD refused Famotidine on multiple occasions due to its liquid form, but the facility failed to notify the physician of these refusals. Staff interviews confirmed the lack of communication, and the DON acknowledged the oversight, unable to provide evidence of physician notification.
A resident with a history of Peripheral Artery Disease and bilateral below-knee amputations was observed to have pressure ulcers. During a dressing change, an LPN did not follow physician orders for wound care, soaking a wound for only 2 minutes instead of 10 and failing to apply skin prep. The DON could not provide evidence that treatments were administered as ordered.
A resident with multiple health conditions, including Crohn's disease and chronic osteomyelitis, experienced a significant weight gain of 12.27% over one month, which was not addressed according to facility policy. Despite the requirement for reweights and physician notification, these actions were not taken until identified by a surveyor. Interviews with staff revealed a lack of awareness and action regarding the resident's weight gain.
A pharmacist failed to report medication irregularities for a resident prescribed as-needed Seroquel, an antipsychotic, without a stop date. Despite facility policy requiring monthly reviews and reporting of irregularities, the pharmacist's recommendations were not communicated to the facility, resulting in the resident receiving the medication without the recommended 14-day stop date.
A facility failed to maintain a medication error rate below 5%, resulting in a 6.25% error rate. A resident's Depakote was crushed against packaging instructions, and MiraLAX was not administered but signed off as given. A CMT acknowledged the error, and an RN confirmed the discrepancies.
A resident with multiple health issues, including muscle weakness and failure to thrive, was found unable to reach their call light, which was tied to the bed rail on the opposite side of the bed. This oversight was acknowledged by a nursing assistant and the DON, who confirmed the care plan was not followed.
A resident with significant weight loss and multiple diagnoses did not receive a prescribed nutritional supplement for 5 out of 16 opportunities due to the supplement being on back order. The deficiency was acknowledged by the DON.
The facility failed to ensure that the environment was free from accident hazards for two residents at moderate risk for falls. One resident with dementia was observed trying to get up from a wheelchair without the call light within reach, and another resident with bipolar disorder was in pain and unable to locate the call light. Staff acknowledged that the call lights were not within reach as required.
Failure to Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized care plans with measurable objectives and timeframes to meet the medical, nursing, mental, and psychosocial needs of residents. This deficiency was identified for five residents, each with specific needs related to their diagnoses and conditions. For instance, one resident with multiple sclerosis and spastic quadriplegia experienced a fall from bed due to inadequate assistance during morning care, highlighting the lack of a focused care plan addressing their ADL needs. Another resident with muscle weakness and dementia required substantial assistance with ADLs, yet their care plan lacked a person-specific approach detailing the level of staff assistance required. Similarly, a resident with PTSD and Parkinson's disease had a care plan that failed to address their specific needs, including a culturally competent and trauma-informed approach for PTSD. The deficiency was further compounded by the facility's reliance on verbal communication among staff to determine the level of assistance needed for residents, rather than utilizing comprehensive care plans. Interviews with staff revealed inconsistencies in the documentation and communication of residents' care needs, with some staff unaware of the care plans or relying on undated and incomplete documents.
Improper Storage of Medications in Resident's Room
Penalty
Summary
The facility failed to store medications in accordance with currently accepted professional principles for a resident who was admitted with diagnoses including arthritis and muscle weakness. A physician's order dated October 1, 2024, prescribed a lidocaine adhesive patch 4% to be applied to the resident's right shoulder every morning and removed at bedtime. However, there was no evidence of an assessment for the resident's self-administration of the medication, which would indicate the resident's safety in storing and administering their medications. During a surveyor observation on November 4, 2024, five unopened lidocaine patches were found in the resident's room. Interviews with an LPN and the Assistant Director of Nursing Services confirmed that the patches should not have been in the resident's room and should have been stored in the medication cart instead.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles, as observed during a survey. On the 2 East Medication Cart, several medications, including Latanoprost Solution, Timolol Maleate Gel Forming Solution, Artificial Tears Ophthalmic Solution, and brimonidine-timolol drops, were found to be expired but not discarded. The Certified Medication Technician, Staff E, acknowledged the oversight during the surveyor's observation. Additionally, the Registered Nurse, Staff D, confirmed that staff should be dating medications when opened and discarding them upon expiration. Further observations on the 2 [NAME] Medication Cart revealed multiple bottles of eye drops, such as Cosopt, Artificial Tears Ophthalmic Solution, Systane Complete PF, and brimonidine-timolol drops, that were opened but undated, leaving their expiration status unknown. Staff F admitted to being unsure of the expiration dates. In the 2 East Medication Room, a multidose vial of Aplisol was found opened and undated, with RN Staff D unable to provide evidence of when it was opened. The Director of Nursing Services expressed that staff are expected to date medications when opened and discard them appropriately.
Failure to Maintain Infection Control for BIPAP Device
Penalty
Summary
The facility failed to maintain an infection prevention and control program for a resident using a Bilevel Positive Airway Pressure (BIPAP) device. The manufacturer's instructions for the BIPAP device, dated July 2017, require that the flexible tube and mask be cleaned before first use and daily thereafter. However, the facility did not follow these instructions for Resident ID #77, who was readmitted in August 2024 with diagnoses including sleep apnea and acute respiratory failure. The resident, who had intact cognition, reported to the surveyor that the facility did not clean their BIPAP machine. A review of the Treatment Administration Record for August and September 2024 showed that the resident had an order to use the BIPAP machine every night, but there was no order to clean the mask and tubing. The Director of Nursing Services confirmed that the facility's policy is to follow the manufacturer's instructions for cleaning the BIPAP equipment, but acknowledged that there was no order to clean the equipment for the resident and could not provide evidence that the machine was cleaned as required.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to meet professional standards of quality for a resident with medication refusals. The resident, who was readmitted to the facility with a diagnosis of gastro-esophageal reflux disease (GERD), had a physician's order for Famotidine, a medication prescribed to treat GERD. The medication was not administered on multiple occasions due to the resident's refusal, specifically on six different dates. Despite these refusals, there was no evidence that the provider was notified about the resident's refusal to take the medication. Interviews with facility staff revealed that the resident often refused the medication because it was in liquid form, although the resident was willing to take pills. Both a Certified Medication Technician and a Licensed Practical Nurse acknowledged that the provider had not been informed of the refusals. The Director of Nursing Services confirmed that the physician should have been notified if a patient was not taking a medication, but he was unable to provide evidence that this notification occurred.
Failure to Follow Wound Care Orders for Resident at Risk for Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident at risk for pressure ulcers, as observed during a survey. The resident, who was admitted in May 2023, has a medical history that includes Peripheral Artery Disease, Peripheral Vascular Disease, and bilateral below-knee amputations. The resident's care plan identified a risk for impaired skin integrity, with existing pressure ulcers on the coccyx, right lower shin, and right lateral knee. Physician orders specified detailed wound care procedures, including the use of Vashe wound cleanser and skin prep application to peri-wounds. During a dressing change observation, it was noted that the LPN, Staff C, did not adhere to the physician's orders. The coccyx wound was soaked with Vashe for only 2 minutes instead of the prescribed 10 minutes, and skin prep was not applied to the peri-wounds as required. Staff C acknowledged the failure to follow the orders during interviews. The Director of Nursing Services could not provide evidence that the treatments were administered as ordered, indicating a lapse in following professional standards of practice for wound care.
Failure to Address Significant Weight Gain in Resident
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, as evidenced by a significant weight gain that was not addressed in accordance with the facility's policy. The resident, who was admitted with conditions including Crohn's disease, rectal abscess, pressure ulcer, and chronic osteomyelitis, experienced a weight gain of 14.4 pounds, or 12.27%, over the course of one month. Despite the facility's policy requiring reweights and notification of the physician if a significant weight discrepancy is noted, there was no evidence that these actions were taken until the issue was identified by a surveyor. Interviews with facility staff, including a registered nurse, the dietitian, and the Director of Nursing Services, revealed a lack of awareness and action regarding the resident's significant weight gain. The registered nurse acknowledged the alarming nature of the weight gain, especially given the resident's fluid restriction, but confirmed that no reweights were obtained and the physician was not notified. The dietitian, who reviews weights weekly, was unaware of the extent of the weight gain and had not reported it to the physician. The Director of Nursing Services also confirmed that he was unaware of the situation until it was brought to his attention by the surveyor.
Pharmacist's Failure to Report Medication Irregularities
Penalty
Summary
The deficiency involves a failure by the facility's pharmacist to report medication irregularities for a resident prescribed as-needed antipsychotic medication. The facility policy requires a monthly drug regimen review by a licensed pharmacist, who must report any irregularities to the attending physician, Medical Director, and Director of Nursing Services (DNS). However, for one resident with a history of major depressive disorder, anxiety disorder, post-traumatic stress disorder, and paranoid personality disorder, the pharmacist did not report the absence of a stop date for the antipsychotic medication Seroquel, which was prescribed as needed. The resident was admitted with a physician's order for Seroquel without a stop date, and the pharmacy made recommendations on two occasions, but these were not communicated to the facility. The DNS was unaware of the pharmacist's recommendations until the surveyor's inquiry, indicating a lapse in communication and adherence to the facility's medication regimen review policy. The failure to report and act on the pharmacist's recommendations resulted in the resident receiving the medication without the recommended 14-day stop date, highlighting a deficiency in the facility's medication management process.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 6.25% error rate during a medication administration task. This deficiency involved a resident who had physician's orders for Depakote and MiraLAX. During an observation, a Certified Medication Technician failed to administer MiraLAX and crushed a Depakote tablet, despite the packaging instructions indicating not to crush or chew the medication. The technician acknowledged the error when interviewed by the surveyor. Additionally, a Registered Nurse confirmed that the MiraLAX was incorrectly signed off as administered, and acknowledged that the Depakote should not have been crushed.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to provide person-centered care in accordance with a resident's plan of care, specifically regarding the accessibility of the call light for a resident with multiple health issues. The resident, admitted in April 2024, had diagnoses including adult failure to thrive, paroxysmal atrial fibrillation, and muscle weakness. The care plan dated April 18, 2024, included interventions to prevent falls and injuries, such as ensuring the call light was within reach and reminding the resident to call for assistance as needed. During a surveyor observation on July 15, 2024, the resident was found seated in a wheelchair with the call light tied to the bed rail on the opposite side of the bed, out of sight and reach. The resident expressed feeling trapped and having to yell for help due to the inability to access the call light. A nursing assistant acknowledged the oversight and relocated the call bell within the resident's reach. The Director of Nursing Services also acknowledged that the care plan had not been followed in this instance.
Failure to Administer Nutritional Supplement as Ordered
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 nutritional supplements. The resident, who was admitted in October 2023 with diagnoses including acquired absence of the right leg below the knee and type II diabetes mellitus, experienced significant weight loss over a month. A physician's order dated 4/23/2024 prescribed 60 milliliters of an oral nutritional supplement twice daily. However, the resident did not receive the supplement for 5 out of 16 opportunities in May 2024 because it was not available in the facility and was on back order. This deficiency was acknowledged by the Director of Nursing Services during a surveyor interview on 5/9/2024.
Failure to Ensure Call Lights Within Reach for Residents at Fall Risk
Penalty
Summary
The facility failed to ensure that the residents' environment remained as free from accident hazards as possible for two residents identified as being at moderate risk for falls. Resident ID #3, who has a history of dementia and falls, was observed attempting to get up from a wheelchair and calling for help, with the call light hanging approximately 8 feet away from the resident. The Registered Nurse acknowledged that the call light was not within the resident's reach, which was a required intervention in the resident's care plan. Similarly, Resident ID #2, who has a history of urinary tract infection and bipolar disorder, was observed lying in bed and experiencing pain. The resident was unable to locate the call light to request pain medication and asked the surveyor to get the nurse. The Licensed Practical Nurse confirmed that the call light was out of the resident's reach, hanging off the bedside rail. The Director of Nursing Services stated that he would expect residents to have their call lights within reach.
Latest citations in Rhode Island
A cognitively impaired resident with dementia and severe BIMS impairment, care planned and ordered to wear a wander guard with regular placement and function checks, eloped from the facility after being last seen in an activity room with a visitor. Staff later could not locate the resident for dinner, and searches were initiated while the resident’s whereabouts were unknown for several hours. Witnesses, including the Activities Director, Receptionist, another resident’s family member, and the visitor, reported that the resident and visitor exited through the main entrance without a wander guard alarm sounding and without use of a door code. The visitor admitted driving the resident to the spouse’s home without notifying staff. EMS and hospital records documented that the resident had been missing for several hours, was confused, could not recall events, and reported severe throat and chest pain, arriving at the hospital with an ankle monitoring device in place. Upon the resident’s return, the facility discarded the original wander guard without testing its functionality and could not provide evidence of consistent monitoring per policy and physician orders, resulting in an Immediate Jeopardy situation.
A resident with Alzheimer’s disease, dementia, severe cognitive impairment, documented exit-seeking behavior, and a care plan identifying high elopement risk and the use of a wander guard was inadequately supervised. Earlier in the day, an LPN observed the resident attempting to open an exit door and redirected the resident, who was later last seen in their room. The resident subsequently exited a secured unit through a stairwell door that only briefly alarmed and was not connected to the wander guard system, descended to a basement level, and left through an exterior door. Because wander guard sensors were only placed at elevators and not at exit doors or stairwells, the resident’s departure went undetected until a Code Orange was called and the elopement protocol initiated, after which staff located the resident off premises and returned the resident to the facility.
A cognitively intact resident with spinal stenosis and post-stroke hemiplegia/hemiparesis was discharged from the hospital with documented referrals to a spine center for evaluation and possible spinal steroid injections, which were reiterated in a later provider note citing ongoing lower extremity weakness. Despite these physician-ordered referrals and the resident’s repeated attempts to reach the appointment scheduler, the facility did not schedule or facilitate the neurosurgical consultation. The unit secretary, who was responsible for scheduling, reported being unaware of the referrals, and neither she nor the DON could provide any evidence that efforts were made to arrange the appointment, leading to a prolonged delay in the resident’s surgical follow-up.
A resident with dysphagia, autonomic dysfunction, seizure disorder, a G-tube, and dependence on staff for feeding had physician orders and a care plan requiring a minced and moist diet with thin liquids given by spoon only while upright. Video from a room camera showed a nurse providing thin liquids through a straw while the resident was lying down and continuing despite the resident coughing. Additionally, a physician ordered every-shift monitoring and documentation of vital signs, including lung sounds, O2 saturation, temperature, and signs of aspiration for seven days, but the MAR showed that required vital signs were not obtained on multiple shifts. The DON confirmed these deviations from physician orders and expected practice.
A resident with intact cognition and a history of hypertension used the call light for toileting assistance when a CNA entered the room and yelled statements such as not "playing games" and telling the resident to wait, causing the resident to become upset. A nursing supervisor heard the CNA yelling, went to the room, and observed the resident visibly upset, while an LPN’s written statement described the CNA’s tone as very rude and yelling about having been with another resident. The CNA later acknowledged speaking loudly to the resident, and during interviews, the administrator and DON could not demonstrate that the resident had been free from verbal abuse as required by the facility’s abuse prohibition policy.
A resident with Alzheimer’s disease receiving hospice services was observed by an RN to be grimacing, with swelling and bruising of the right ankle, and an x-ray later confirmed displaced fractures of the medial and lateral malleolus. Facility policy required that responsible family or legal representatives be notified within 24 hours of significant condition changes or injuries and that this notification be documented in the medical record. A NP documented the fracture findings and ordered that hospice and the resident’s representative be contacted, but there was no documentation that the representative was notified. In interviews, the resident’s representative reported learning of the injuries from hospice staff, the RN acknowledged not notifying the representative, and the DON could not provide evidence that immediate notification occurred, resulting in a deficiency for failure to notify the representative of a significant change in condition.
A resident with Alzheimer's disease, severe cognitive impairment, and non-ambulatory status, receiving hospice care, was found grimacing with swelling and bruising to the right ankle after being brought to the dining room. An x-ray later confirmed acute to subacute displaced fractures of both the medial and lateral malleolus, with no cause identified in the record, making it an injury of unknown origin. A hospice aide reported that during care, the resident became agitated and flailed while two CNAs held the resident's arms and legs, but care was not stopped and the nurse was not notified of the behavior. The RN on duty could not show that the injury of unknown origin was reported to RIDOH, and the DON acknowledged that the incident was not reported, resulting in a failure to report an alleged violation and injury of unknown origin as required.
A non-ambulatory hospice resident with severe cognitive impairment developed swelling and bruising of the right ankle after being taken to the dining room and receiving care in the room, during which the resident became agitated and flailed while a hospice aide and two CNAs continued care and physically held the resident’s arms and legs. An RN later noted the ankle changes, obtained an x-ray order from a provider, and imaging confirmed acute to subacute displaced fractures of both the medial and lateral malleolus. The clinical record and interviews with the RN, DON, and NP showed that no thorough investigation was conducted into the origin of the injury, no potential causes were documented or identified, and no interventions to prevent further or potential injury were documented, despite regulatory requirements and a community complaint alleging lack of notification and unclear cause of the injury.
A resident with CHF, afib, moderate cognitive impairment, and low body weight was mistakenly given another resident’s clozapine 150 mg and melatonin 3 mg by a CMT who entered the wrong room and failed to verify identity, contrary to facility policy requiring multiple resident-identification checks. The resident did not receive ordered warfarin and metoprolol during this pass. Subsequently, the resident was found unresponsive with abnormal respirations, tachycardia, and hypoxia, required EMS intervention with suctioning, high-flow oxygen via BVM, and IV emergency cardiac medication, and was admitted to the hospital with altered mental status, profound hypothermia, pleural effusion, and aspiration pneumonia, later transitioning to comfort care and expiring. The DON was unable to show the resident was kept free from significant medication errors, and the Medical Director stated she expected correct medications to be given to the correct resident.
The facility failed to ensure that a CMT had demonstrated competency in resident identification during medication administration and did not complete the required quarterly medication aide evaluations. Despite only one documented evaluation and no evidence of competency in verifying resident identity, the CMT was scheduled to pass medications and entered the wrong room, administering clozapine 150 mg and melatonin 3 mg intended for another resident to a frail, elderly resident with CHF and Afib. The resident, who weighed 79.2 pounds, subsequently developed tachycardia, shortness of breath, altered mental status, profound hypothermia, a small pleural effusion, and aspiration pneumonia, was admitted to the hospital for comfort measures only, and later died. The DON acknowledged that quarterly evaluations were required and could not provide evidence that the CMT had demonstrated competency in medication administration per state requirements.
Elopement of Cognitively Impaired Resident Despite Wander Guard Device
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary supervision and maintain an effective elopement prevention system for a cognitively impaired resident identified as an elopement risk. The resident had diagnoses including dementia, cognitive communication deficit, and anxiety disorder, and a Quarterly MDS showed a BIMS score of 4/15, indicating severe cognitive impairment. The resident’s care plan, initiated after prior attempts to leave the facility, required use of a wander guard bracelet, weekly assessment of the device’s functioning and battery status, and visual checks or supervision for safety. Physician orders directed staff to check placement of the Tektone wander guard bracelet every shift and to check its functionality weekly. Documentation on the March Treatment Administration Record indicated the device was in place on the day of the incident and that its functionality had been checked and found operational several days earlier. On the day of the elopement, staff observed the resident wearing the wander guard bracelet in the activities room during a bingo activity in the mid-afternoon. An LPN reported last seeing the resident in the activity room seated with a visitor and wearing the wander guard. Later, when the LPN attempted to escort the resident to dinner, the resident could not be located, and a subsequent call to the resident’s spouse confirmed that the spouse did not have the resident and was unaware the resident was missing. The facility’s elopement protocol was then initiated, and staff, along with law enforcement, conducted searches of the building and surrounding community. During this time, staff and management did not know the resident’s whereabouts for several hours. Interviews and witness accounts established that the resident exited the facility through the main entrance with a visitor. The Activities Director stated that she did not see the resident or visitor leave and did not hear a wander guard alarm at the exit. The Receptionist reported seeing the resident and a visitor walking toward the main entrance and also did not hear an alarm. A visitor later admitted that she removed the resident from the facility at the resident’s request to go home, drove the resident to the spouse’s house, dropped the resident off, and left without notifying staff; she stated that the wander guard alarm did not sound when they exited and that she had never been given a door code. A family member of another resident reported seeing the visitor leave with the resident through the main entrance without hearing an alarm or seeing a code entered. The resident ultimately arrived at the spouse’s home with a sandwich in hand, appeared confused, and could not explain how they had gotten there. EMS and hospital records documented that the resident had been missing from the facility for several hours, could not recall their whereabouts, and reported severe throat and chest pain; the hospital record also noted that the resident arrived with an ankle monitoring device in place. Following the resident’s return, the facility did not evaluate or test the wander guard device that had been in use at the time of the elopement. A Regional Nurse documented that a new wander guard device was applied to the resident’s left ankle, and later acknowledged in interview that the original device had been discarded without assessment. The Regional Administrator and Regional Nurse were unable to provide evidence that the previous device had been checked or tested for functionality upon the resident’s return. The Administrator stated that it was unclear whether the wander guard system had failed, whether an alarm had sounded without staff response, or whether a visitor had entered a door code, and confirmed that visitors should not have the door code. The facility was also unable to provide documentation confirming that staff consistently monitored the resident in accordance with facility policy and physician orders. These failures resulted in the resident leaving the facility unsupervised for approximately six hours while staff were unaware of the resident’s whereabouts, placing the resident at risk for serious injury, serious harm, serious impairment, or death, and constituted a situation of Immediate Jeopardy.
Failure of Elopement Prevention and Supervision for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and maintain an effective elopement prevention system for a resident assessed as a high elopement risk. The resident had Alzheimer’s disease, dementia, severe cognitive impairment (BIMS score of 00), a documented history of exit-seeking behaviors, and a care plan identifying high elopement risk, prior elopements, recent attempts to leave, verbalizations about leaving, and wandering behavior requiring a wander guard. On the morning of the incident, an LPN observed the resident attempting to open the unit exit door at approximately 9:30 AM; the resident was redirected and escorted back to the dining room. The resident was last seen in their room at approximately 10:00 AM. Despite residing on a secured unit and wearing a wander guard, the resident eloped from the unit via a stairwell door that alarmed when opened but stopped alarming after the door closed and after a period of time. The wander guard system was configured so that sensors were only located at the elevators and did not detect the resident at the unit exit doors or stairwell. The resident used the stairwell to descend several flights to the basement level and exited through a basement exterior door, leaving the building undetected. A Code Orange was not called and the elopement protocol not initiated until approximately 11:20 AM, at which time the resident had already traveled off premises and was later observed walking along a main road and crossing a four-lane street before being located and returned to the facility at approximately 11:45 AM.
Failure to Arrange Neurosurgical Follow-Up for Resident With Spinal Stenosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services were provided in accordance with professional standards of quality for a resident admitted with spinal stenosis and post-stroke hemiplegia/hemiparesis. The resident was admitted in October 2025 with diagnoses including spinal stenosis and left-sided weakness following a stroke. A Continuity of Care - Post-Acute Facility document dated 10/24/2025 indicated that, upon hospital discharge, a referral to a spine center was placed to evaluate the need for spinal steroid injections. A subsequent provider progress note dated 11/17/2025 documented the resident’s ongoing chronic lower extremity weakness related to lumbar disc protrusions and reiterated the need for outpatient neurosurgical follow-up, with an additional referral placed at that time. Record review and interviews showed that, despite these clear and repeated physician-ordered referrals, the facility did not schedule or facilitate the required neurosurgical consultation. The resident, who had a Brief Interview for Mental Status score of 14/15 indicating cognitive intactness and ability to express needs, reported making multiple unsuccessful attempts to contact the facility’s appointment scheduler to obtain the neurosurgical consultation for spinal injections. During an interview, the Unit Secretary responsible for scheduling appointments stated she was unaware of the referrals, and neither she nor the Director of Nursing Services could provide evidence that any efforts were made to arrange the neurosurgical appointment. A community complaint alleged that the resident waited approximately five months without resolution of the needed surgical follow-up appointment.
Failure to Follow Physician Orders for Dysphagia Management and Vital Sign Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of practice and followed physician orders for a resident with significant swallowing difficulties and other complex medical conditions. The resident, admitted with diagnoses including seizure disorder, autonomic dysfunction, presence of a gastrostomy tube, bilateral upper extremity contractures, and dysphagia, was dependent on staff for eating. A physician’s order dated 1/6/2026 specified a house diet with minced and moist texture and thin liquids to be provided by spoon only. The care plan initiated on 12/4/2024 also identified swallowing difficulty and included an intervention to provide thin liquids via spoon. A community complaint and video footage from the resident’s room showed that during an overnight shift, a nurse gave the resident a drink using a straw while the resident was lying down and continued to provide liquids while the resident was coughing, contrary to the physician’s order and care plan. The DON confirmed, after reviewing the video, that the nurse provided thin liquids with a straw while the resident was not upright and continued despite the resident’s coughing. The facility also failed to follow a physician’s order related to monitoring for possible aspiration. A physician’s order dated 3/19/2026 directed staff to obtain and document the resident’s vital signs, including lung sounds, oxygen saturation, temperature, and signs and symptoms of aspiration such as coughing or runny nose, every shift for seven days. Review of the March 2026 Medication Administration Record showed that vital signs were not obtained during the 3:00 PM–11:00 PM and 11:00 PM–7:00 AM shifts on 3/23/2026, and the 11:00 PM–7:00 AM shift on 3/24/2026. In an interview, the DON stated she expected vital signs to be obtained and documented each shift as ordered and acknowledged that the facility failed to ensure physician orders were followed for this resident.
Failure to Protect a Resident From Verbal Abuse by Nursing Assistant
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by a nursing assistant. The resident was admitted with diagnoses including hypertension and had an admission MDS Brief Interview for Mental Status score of 15/15, indicating intact cognition. On the evening in question, after the resident used the call light for toileting assistance, Nursing Assistant Staff A entered the room and yelled, "I'm not playing games with you tonight, you keep pressing the call light, and I told you to wait." The resident reported being upset by this interaction. A Nursing Supervisor, Staff B, who was on duty at the time, responded to the resident’s room after hearing Staff A yelling and observed the resident to be visibly upset. An LPN, Staff C, provided a written statement indicating she heard Staff A speaking in a very rude tone and yelling, "I told you to wait, I was with another resident." Staff A’s own written statement acknowledged that she spoke back to the resident loudly. During an interview with the Administrator and the Director of Nursing Services, they acknowledged the findings and were unable to provide evidence that the resident was free from verbal abuse during this incident, in contrast to the facility’s abuse prohibition policy defining verbal abuse as disparaging or derogatory oral, written, or gestured language within a resident’s hearing.
Failure to Notify Resident Representative of Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s representative of a significant change in condition, specifically an injury of unknown origin resulting in right ankle fractures. The facility’s policy dated 10/19/2023 requires responsible family members or legal representatives to be notified as soon as possible, or within 24 hours, of any changes in the resident’s condition, including significant physical changes and any accidents resulting in injury, with documentation of such notification in the medical record. The resident, admitted in October 2025 with Alzheimer’s disease and receiving hospice services, was observed on 3/9/2026 by an RN to be grimacing after being brought to the dining room, and further assessment revealed swelling and bruising of the right ankle. An x-ray was ordered and later confirmed acute to subacute fractures of the medial malleolus with displacement and a moderately displaced fracture of the lateral malleolus. A subsequent progress note by a nurse practitioner documented the fracture findings and included an order to contact hospice and the resident’s representative to review the results. However, record review did not show any evidence that the resident’s representative was notified by the facility of the injuries, nor was there documentation of such notification in the medical record as required by policy. During interviews, the resident’s representative stated that they were not notified by the facility and instead learned of the injuries from hospice staff. The RN who first identified the bruising and swelling acknowledged that she did not notify the resident’s representative. The Director of Nursing Services was unable to provide evidence that the resident’s representative was immediately notified when the injuries were identified, confirming the failure to follow the facility’s notification policy.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
The facility failed to timely report an injury of unknown origin to the Rhode Island Department of Health (RIDOH) for a resident with Alzheimer's disease who was non-ambulatory, dependent on staff for all transfers, and had severe cognitive impairment. The resident, who was on hospice services, was brought to the dining room by staff and was later observed grimacing, with swelling and bruising to the right ankle. An x-ray obtained that evening confirmed acute to subacute fractures of both the medial and lateral malleolus with displacement. A subsequent nurse practitioner note documented the fracture findings and included an order to contact hospice and the resident's representative, but the clinical record did not identify a cause for the injury, classifying it as an injury of unknown origin. Record review also failed to show that this injury of unknown origin was reported to RIDOH. During interviews, a hospice aide reported that after lunch she provided care to the resident in the room, accompanied by two CNAs. She stated the resident was not in discomfort before care, but became agitated during care and flailed upper and lower extremities, while one CNA held the resident's legs and another held the resident's arms; she did not stop care or notify the nurse of the resident's behavior. After care, the resident was transferred to a chair and returned to the dining room, and the aide later learned of the swollen ankle after returning from lunch, without knowing how the injury occurred. The RN on duty at the time of injury identification was unable to provide evidence that the injury of unknown origin was reported to RIDOH, and the Director of Nursing Services acknowledged that the facility did not report the injury to RIDOH, confirming the failure to report the alleged violation and injury of unknown origin as required.
Failure to Investigate Injury of Unknown Origin and Identify Cause of Ankle Fractures
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an injury of unknown origin for a non-ambulatory resident with Alzheimer’s disease who was dependent on staff for all transfers and had severe cognitive impairment. The resident, who was on hospice services, was brought to the dining room by staff and later exhibited grimacing, with swelling and bruising noted to the right ankle. An x-ray obtained the same day confirmed acute to subacute displaced fractures of both the medial and lateral malleolus. Although the nurse on duty notified the provider and obtained the x-ray order, the clinical record lacked documentation of any investigation into how the injury occurred, any determination or discussion of potential causes, or identification of the origin of the fractures. Surveyor interviews revealed that a hospice aide, accompanied by two CNAs, had taken the resident to the room after lunch to provide care. During care, the resident, who had not shown discomfort beforehand, became agitated and flailed upper and lower extremities while one CNA held the resident’s legs and another held the resident’s arms; care was continued despite the agitation, and the nurse on duty was not notified of this behavior. After care, the resident was transferred to a chair and returned to the dining room, and the hospice aide later learned of the swollen ankle but did not know how the injury occurred. The RN who discovered the swelling and bruising, the DON, and the NP all acknowledged there was no thorough investigation, no documentation establishing the origin of the injuries, and no evidence of implemented measures to prevent further or potential injury, and the facility could not provide investigative findings or evidence of required reporting.
Fatal Medication Error Due to Failure to Verify Resident Identity
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when a Certified Medication Technician (CMT) administered another resident’s medications without verifying identity. On the evening medication pass, the CMT, identified as Staff A, entered the wrong room and gave clozapine 150 mg and melatonin 3 mg, which were prescribed for a different resident, to Resident ID #1. This administration occurred despite a facility policy requiring staff to verify resident identity using methods such as checking an identification band, reviewing a photograph attached to the medical record, and, if necessary, confirming identity with other personnel. All patient identifiers were missed, and the resident did not receive his or her regularly scheduled medications, including warfarin 0.5 mg and metoprolol 12.5 mg. Resident ID #1 had been admitted in October 2025 with diagnoses including congestive heart failure and atrial fibrillation and was over a specified advanced age. A recent MDS assessment showed moderately impaired cognition with a Brief Interview for Mental Status score of 10 out of 15. The resident weighed 79.2 pounds, and the provider documented that the clozapine dose administered in error was a significant concern given the resident’s small body habitus. Record review confirmed there were no physician orders for clozapine 150 mg or melatonin 3 mg for this resident. Following the medication error, progress notes documented that late on the night of the error, the LPN (Staff B) recorded that the resident had received another resident’s medications and had missed his or her own scheduled warfarin and metoprolol. The next morning, staff found the resident unresponsive with abnormal breathing, pale skin, a heart rate of 136 bpm, and an oxygen saturation of 90%, prompting transfer via EMS. EMS records described the resident as unresponsive with audible gurgling, excessive oral secretions requiring suctioning, a fast and irregular heart rate between 150–190 bpm, and severely depressed respirations requiring bag-valve-mask support and IV emergency heart medication. Hospital records documented elevated heart rate, shortness of breath, altered mental status, profound hypothermia, a chest x-ray showing a small left pleural effusion and aspiration pneumonia, and subsequent transition to end-of-life care, with the resident expiring several days later. During interviews, the DON could not demonstrate that the resident was kept free from significant medication errors, and the Medical Director stated she would have expected the correct medications to be administered to the right resident.
Failure to Ensure CMT Medication Competency and Required Quarterly Evaluations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a Certified Medication Technician (CMT) had the required competencies and quarterly evaluations to safely administer medications, as required by Rhode Island regulations. State regulations mandate that medication technicians must complete a State‑approved course, demonstrate competency in drug administration, and receive quarterly evaluations by the Director of Nursing (DON) or RN designee, with documentation placed in personnel files. The facility’s own assessment stated that department‑specific training and competencies are completed throughout employment to ensure staff can safely and competently provide the required care. However, review of the CMT’s personnel record showed she was hired as a CMT/Nursing Assistant and had only one medication administration evaluation since hire, with no evidence of the four required quarterly evaluations. Record review of the CMT’s “Medication Administration Competency” document showed no evidence that she had demonstrated competency in identifying a resident prior to medication administration. Despite this, she was scheduled to administer medications periodically. On the evening in question, the CMT entered the wrong room and administered medications intended for another resident to Resident ID #1, without verifying the resident’s identity and missing all patient identifiers. The medications administered in error included clozapine 150 mg and melatonin 3 mg, which were prescribed for another resident. Resident ID #1 had been admitted in October 2025 with diagnoses including congestive heart failure and atrial fibrillation and was over a specified advanced age. Following the medication error, a provider note documented that the CMT had administered the wrong medications by entering the wrong room and failing to verify identity, and that the clozapine dose was of significant concern given the resident’s low body weight of 79.2 pounds. The resident subsequently presented to the hospital with elevated heart rate, shortness of breath, and altered mental status, was found to have profound hypothermia, a small left pleural effusion, and aspiration pneumonia, and was admitted for inpatient comfort measures only. The resident later expired. The DON acknowledged that medication aide evaluations are required at least quarterly and was unable to provide evidence that the CMT had demonstrated competency in medication administration per state requirements.
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