Grand Islander Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Middletown, Rhode Island.
- Location
- 333 Green End Avenue, Middletown, Rhode Island 02842
- CMS Provider Number
- 415034
- Inspections on file
- 27
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Grand Islander Center during CMS and state inspections, most recent first.
A resident with hyperosmolality and hypernatremia did not receive a repeat BMP as ordered by the provider. Record review showed the test was not completed on the scheduled date, and the DON confirmed the expectation that the order should have been followed.
A resident with a psychotic disorder did not receive medically related social services after being issued a 30-day discharge notice for non-payment. The resident subsequently displayed disruptive and self-injurious behaviors, including an incident involving a plastic bag, leading to hospital transfer. Documentation and interviews confirmed that the Social Worker did not engage with the resident or their family after the notice, and no support or case management was provided despite requests.
A resident with Parkinson's disease, assessed as needing two-person assistance with a gait belt for transfers, was routinely transferred by a single nursing assistant using a stand pivot transfer. This failure to follow the care plan led to the resident sustaining significant fractures to the left tibia and fibula, with staff and the resident confirming that transfers were often performed without the required assistance.
A resident with a history of skin cancer and recent MOHS surgery did not receive wound care as ordered by a dermatologist, including specific soaks and Manuka Honey applications. Facility records showed no evidence that these orders were implemented or verified by the facility physician, and the Administrator could not provide documentation to support that the orders were followed.
A resident with severe cognitive impairment, a history of falls, and a recent hip fracture was left to ambulate alone with a walker when a nursing assistant walked ahead, contrary to the care plan and PT recommendations requiring supervision or stand-by assistance. The resident let go of the walker, fell, and sustained a hip fracture. Staff interviews confirmed a misunderstanding of the resident's supervision needs, and there was no evidence that proper supervision was provided.
Two residents with complex care needs did not have comprehensive, person-centered care plans in place. One resident who suffered a fall with injury and required hospitalization did not have this event addressed in their care plan. Another resident with multiple mobility issues had conflicting instructions in their care plan regarding transfer devices, with no clear specification of the appropriate method. The DON was unable to provide documentation of accurate, individualized care plans for these residents.
A nursing assistant did not receive required Abuse Prohibition training upon hire, as revealed during an investigation into an alleged staff-to-resident abuse incident involving a resident with multiple sclerosis and rheumatoid arthritis who was cognitively intact. The DON confirmed that there was no documentation of the mandated training for the staff member.
Three residents with care plans requiring weekly skin assessments did not receive these assessments as scheduled. Documentation was missing for multiple weeks, and staff were unable to provide evidence that the assessments were completed, despite care plans specifying this intervention for residents with stroke and dementia diagnoses.
Nursing staff, including RNs and LPNs, did not complete required annual competencies and skill assessments, including IV therapy and PICC line management, as outlined in the facility assessment. Documentation confirming completion of these competencies was not available during surveyor review.
Surveyors found that medications were left unattended, not properly dated when opened, and expired or discontinued drugs were not discarded as required. Staff acknowledged that medications such as insulin pens, inhalers, and oral solutions were either expired, lacked opening dates, or were prescribed for residents no longer present, but remained in storage or on medication carts.
Surveyors found that the facility did not implement Enhanced Barrier Precautions (EBP) for two residents with wounds and one resident with a urinary catheter. Required EBP signage was missing from room doors, and staff were unaware of the need for EBP or PPE use during high-contact care activities, despite physician orders for wound and catheter care. The unit manager and clinical advisor confirmed these lapses, indicating a breakdown in infection control procedures and staff training.
Three residents with documented preferences for watching TV were unable to do so for several days due to a power outage affecting their room outlets. Despite their care plans and MDS assessments highlighting the importance of television as a preferred activity, no alternative means, such as tablets, were provided, leaving the residents without meaningful activities and causing dissatisfaction.
A resident with impaired mobility and a history of skin breakdown did not consistently receive preventative skin care or weekly skin assessments as required by their care plan. Staff failed to document or provide preventative skin care for most opportunities in a month, and weekly skin checks were not completed after the initial assessment. The resident developed pink, blanchable areas on the buttocks, and staff interviews confirmed the lack of adherence to the care plan.
A resident with multiple medical conditions experienced a significant weight loss over a short period, but the facility failed to implement nutritional interventions or notify the dietitian and physician as required by policy. Despite regular weight monitoring, the decline was not addressed, and key clinical staff were unaware of the extent of the weight loss.
A resident receiving IV antibiotics via a PICC line for enterococcal bacteremia did not have required documentation of external catheter length or upper arm circumference, as ordered by the physician. Nursing staff signed off on dressing changes that were not performed, and facility records lacked evidence of proper monitoring and documentation for the PICC line.
A resident requiring hemodialysis did not have a physician's order for routine monitoring of their dialysis access site for bruit and thrill, as required by facility policy and the care plan. Documentation showed that the last assessment was performed several months prior, and staff confirmed the absence of an order until the issue was identified by surveyors, resulting in a lapse in monitoring consistent with professional standards.
The facility did not ensure that provider review and action occurred on pharmacist-identified medication regimen irregularities for three residents, including recommendations regarding insulin and oral diabetes medication dosing, PRN lorazepam use, duplicate PRN orders, and clarification of acetaminophen and Miralax administration.
A resident with a history of atrial fibrillation and cardiac conditions did not receive prescribed doses of Warfarin on two consecutive days, as documented in the MAR. This omission was confirmed by staff and resulted in a subtherapeutic PT/INR level, indicating a significant medication error.
Surveyor observation of the dumpster area, with the Food Service Director present, found various discarded items such as cardboard boxes, used masks, bubble wrap, wood pieces, a mattress, and a metal bed frame scattered on the ground. The Maintenance Director acknowledged the need for cleanup and proper disposal of these items.
The facility did not follow its antibiotic stewardship protocols for two residents with indwelling catheters. In both cases, antibiotics were started without proper documentation of required clinical criteria or completion of an antibiotic time-out, and in one instance, a urine culture later showed no bacterial growth. Facility staff acknowledged these lapses and could not provide evidence that the stewardship program was followed.
A resident with a history of stroke experienced a fall resulting in a laceration that required sutures and transfer to an acute care hospital. Facility records did not show that the resident's representative was immediately notified of the incident and transfer, and staff could not provide evidence of timely notification, resulting in a deficiency.
The facility did not complete or document required neurological assessments for two residents after falls, including one with a head injury and another with dementia, despite facility policy and provider recommendations. The Assistant Director of Nursing confirmed the lack of documentation and incomplete evaluations.
A resident with serious medical conditions experienced significant weight fluctuations that were not properly addressed by the facility. Despite policies requiring re-weighing after significant weight changes, the resident was not re-weighed, and there was incomplete documentation of meal and snack intake. Staff interviews confirmed these deficiencies, and the dietitian was not informed of the weight loss, preventing timely nutritional intervention.
A resident with a DNR order passed away within 24 hours of admission, but staff performed CPR and used a defibrillator despite the resident's MOLST form indicating no resuscitation. The ADNS acknowledged the error in following the resident's wishes.
A resident with a Stage IV pressure injury did not receive complete wound care instructions as per professional standards. The physician's order lacked details on wound packing and location, despite being signed off as administered. The DON acknowledged the incomplete order during an interview.
A resident received unnecessary doses of Meropenem due to a transcription error. The resident, admitted with bacteremia and osteomyelitis, was prescribed 49 doses of the antibiotic. However, the resident received four additional doses beyond the prescribed amount. The DON acknowledged the error, attributing it to a nurse's incorrect transcription of missed doses, which led to the administration of extra doses.
Surveyors found deficiencies in food storage and labeling in the facility's main kitchen and kitchenettes. Unlabeled and expired food items, including hot dogs, yogurt, and milk, were observed, contrary to the facility's policy requiring labeling and timely disposal. The FSD and staff acknowledged these lapses.
The facility failed to provide routine dental services for two residents with cognitive impairments and dental issues, despite physician orders and evident dental needs. Observations confirmed missing and broken teeth, and staff interviews revealed no evidence of dental care being provided.
The facility failed to maintain proper infection control practices, particularly in the use of Enhanced Barrier Precautions (EBP) and during wound care. Staff were observed not wearing gowns during high-contact activities for residents with MDRO risks, and a nurse failed to perform hand hygiene during a wound dressing change. These actions were contrary to the facility's infection prevention protocols.
Two residents did not receive fortified diets as ordered by their physicians, despite being at nutritional risk. One resident with malnutrition and dysphagia was not given double protein portions and fortified foods, while another resident with dementia experienced significant weight loss without receiving the prescribed fortified diet. Staff interviews confirmed the failure to follow dietary orders.
A resident with sensorineural hearing loss did not receive proper assistance with hearing aids, as required by their care plan and physician's order. Despite a directive for daily application, the hearing aids were only applied once in May. Observations and interviews revealed that staff typically applied the aids only when the resident had visitors, contrary to the order. The DON acknowledged the oversight and expected daily application.
A resident with limited range of motion due to a stroke did not receive a prescribed ankle-foot orthosis (AFO) to assist with mobility. Despite a physician order and casting for the AFO, the device was not provided due to a lack of follow-up by Rehabilitation Services and missing physician authorization. Staff interviews revealed confusion about the process, resulting in the resident not receiving the necessary device.
A resident with muscle weakness and urinary incontinence experienced a deficiency in care when the facility failed to follow the bowel protocol for constipation. Despite having a care plan and physician's orders in place, the resident did not have a bowel movement for six days, and the protocol was not followed. Staff interviews revealed a lack of communication and understanding of the protocol, and the DON acknowledged the failure to initiate the protocol and notify a provider.
A resident with end-stage renal disease and hypertension did not receive appropriate dialysis care due to a lack of communication between the LTC facility and the dialysis center. Despite elevated blood pressure readings, the facility failed to follow up with the dialysis center or notify the physician after the dialysis center left the communication sheet blank. Interviews revealed inconsistencies in sending communication sheets, and the Director of Nursing could not provide evidence of effective communication or physician notification.
A resident with a history of stroke and mobility issues did not receive a required physical therapy evaluation, as identified in their care plan. Despite the resident's expressed need for more therapy and an Occupational Therapy screen requesting a PT evaluation, the facility failed to complete it. Interviews with the Director of Rehabilitation Services and the DON confirmed the expectation for the evaluation, but no evidence of its completion was found.
Failure to Complete Ordered Blood Work
Penalty
Summary
A deficiency was identified when a resident with a diagnosis including hyperosmolality and hypernatremia was admitted to the facility and subsequently had abnormal blood work. The provider gave new orders, including a repeat basic metabolic panel (BMP) to be drawn on a specified date. Record review showed that the physician's order for the repeat BMP was not carried out as scheduled, and there was no evidence that the test was completed on the ordered date. During an interview, the Director of Nursing Services confirmed that the BMP should have been completed as ordered.
Failure to Provide Social Services Following Discharge Notice
Penalty
Summary
The facility failed to provide medically related social services to support a resident with a history of psychotic disorder and hallucinations after issuing a 30-day discharge notice for non-payment. Following the notice, the resident exhibited disruptive and self-injurious behaviors, including being found with a plastic bag over their head, which required immediate intervention and 1:1 supervision until transfer to an acute care hospital for psychiatric evaluation. Documentation and staff interviews revealed that the Social Worker was aware of the resident's distress and the presence of the resident and family at the facility but did not successfully engage with them or provide support after the notice was issued. Further review showed no evidence that the Social Worker or facility staff provided or attempted to provide the required social services to the resident or their representative following the issuance of the 30-day notice. Staff interviews confirmed expectations that social services should have intervened, and the resident's representative reported being unaware of the Social Worker's availability and not being offered case management support, despite requesting it. The lack of social service intervention was not addressed until after surveyor inquiry.
Failure to Provide Required Two-Person Assistance During Transfer Results in Resident Fractures
Penalty
Summary
A resident with Parkinson's disease, who was cognitively intact and required the assistance of two staff members with a gait belt for transfers, sustained significant fractures to the left tibia and fibula. The resident's care plan and transfer evaluation clearly documented the need for two-person assistance during transfers. However, staff interviews and documentation revealed that the resident was routinely transferred by a single nursing assistant using a stand pivot transfer (SPT) technique, contrary to the care plan requirements. Multiple staff members, including nursing assistants and the Director of Rehabilitation, confirmed that the resident was often transferred independently and that the resident had difficulty lifting their foot during transfers, which led to twisting of the leg. The resident reported hearing a pop and falling backward during a transfer when only one staff member was present. Staff schedules confirmed that the staff involved were on duty during the relevant period, and there was no evidence provided by the facility to show that two-person assistance was consistently provided as required. The investigation determined that the resident's injuries were consistent with improper or inadequate assistance during a transfer, specifically a twisting injury that can occur when a resident is not properly supported. The facility failed to ensure that the resident received adequate supervision and assistance during transfers, as outlined in the care plan and transfer evaluation, which likely contributed to the resident's fractures.
Failure to Implement and Document Physician Wound Care Orders
Penalty
Summary
A resident with a diagnosis including basal cell carcinoma was admitted to the facility and subsequently underwent MOHS surgery to remove skin cancer. Following the procedure, a dermatologist provided specific wound care orders, including daily soaks with a white vinegar and water solution and the application of Manuka Honey to raw areas on the face and neck twice daily until healed. These orders were documented on a Continuity of Care Consultation and Referral Form. Record review revealed that from September through November, there was no evidence in the Treatment Administration Records (TAR) that the dermatologist's wound care orders were implemented. There was also no documentation indicating that the facility physician had declined or verified the dermatologist's orders. During an interview, the Administrator was unable to provide evidence that the orders were followed or that any verification or declination by the facility physician had occurred.
Failure to Provide Adequate Supervision During Ambulation Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of repeated falls, and a recent hip fracture was not provided with adequate supervision during ambulation. The resident required supervision or stand-by assistance with a rolling walker, as documented in the care plan, MDS, and physical therapy discharge summary. On the day of the incident, a nursing assistant walked ahead of the resident, leaving the resident to ambulate alone with a walker. The resident let go of the walker, fell backwards, and subsequently suffered a hip fracture after attempting to get up and being struck by a door. Staff interviews revealed that the nursing assistant believed the resident was independent with walking, contrary to the documented requirements for supervision and assistance. The Director of Rehabilitation confirmed that the resident was not independent and required staff to be within arm's length during ambulation. The Director of Nursing also stated that staff are expected to follow physical therapy recommendations and the care plan, but was unable to provide evidence that adequate supervision was provided at the time of the incident.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with significant care needs. For one resident who was re-admitted with a history of a displaced intertrochanteric fracture of the left femur, documentation showed that the resident experienced a fall resulting in a hip fracture and required hospitalization and surgery. However, review of the resident's care plan did not show any evidence that the actual fall with injury was addressed or incorporated into the care plan, and the Director of Nursing Services was unable to provide documentation of a comprehensive care plan related to this incident. For another resident with diagnoses including a left patella fracture, hip pain, and dementia, the care plan contained conflicting instructions regarding transfer methods. The plan indicated the use of a mechanical lift requiring two staff for transfers, but also referenced the use of a slide board for transfers. Further documentation confirmed the resident was dependent for all transfers, yet the care plan did not specify a single, consistent transfer device. The Director of Nursing Services acknowledged the inconsistency and was unable to provide evidence of a comprehensive, person-centered care plan that accurately reflected the resident's transfer needs.
Failure to Ensure Abuse Prevention Training for Nursing Assistant
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets to provide care that assures resident safety and maximizes well-being, as required by resident assessments and individual care plans. Specifically, a review of records and staff interviews revealed that a nursing assistant, Staff A, did not complete the required Abuse Prohibition training upon hire, as mandated by facility policy. This deficiency was identified during the investigation of an alleged staff-to-resident abuse incident involving Staff A and a resident with multiple sclerosis and rheumatoid arthritis, who was cognitively intact at the time of the incident. Further review showed that the facility's Abuse Prohibition Policy requires all employees to receive training on abuse prevention during orientation and at least annually. However, there was no documentation that Staff A had received this training upon hire or after the abuse allegation was reported. The Director of Nursing Services confirmed the absence of training records for Staff A and acknowledged that additional abuse prevention training would have been expected following the incident.
Failure to Complete Weekly Skin Assessments per Care Plan
Penalty
Summary
The facility failed to implement comprehensive, person-centered care plans for three residents by not completing weekly skin assessments as required. For one resident with a history of stroke, documentation showed that weekly skin inspections had not been completed since early May, despite a care plan directive for weekly assessments. Similarly, another resident with a stroke diagnosis had a care plan for weekly skin inspections, but records indicated that assessments were missed for several consecutive weeks. In both cases, staff interviews confirmed the absence of documentation to support that the required assessments were performed. A third resident, admitted with dementia, also had a care plan specifying weekly skin checks by a licensed nurse. However, documentation revealed that the weekly skin assessment was not completed as scheduled, and the Assistant Director of Nursing was unable to provide evidence that the assessment had occurred. These findings demonstrate that the facility did not follow through with the scheduled care plan interventions for weekly skin assessments for these residents.
Failure to Ensure Nursing Staff Competency and Annual Skills Assessment
Penalty
Summary
The facility failed to ensure that nursing staff, including both registered nurses (RNs) and licensed practical nurses (LPNs), had completed required annual competencies and skill assessments as outlined in the facility assessment. Specifically, there was no evidence that four nurses, hired between 2009 and 2023, had completed their annual nursing competencies since 2023. Additionally, the facility assessment indicated that staff must be competent in providing IV therapy, including the management and administration of medications via a peripherally inserted central catheter (PICC). However, competency records for three nurses did not show completion of the required yearly IV competency for PICC line care. During an interview, the Clinical Market Advisor was unable to provide documentation confirming that any of the identified staff had completed their annual competencies as required by the facility's own assessment. The deficiency was identified through record review and staff interviews, and it was determined that the facility did not ensure staff had the necessary competencies and skill sets to provide safe and appropriate care for the resident population, including those requiring IV therapy.
Failure to Properly Store, Label, and Dispose of Medications
Penalty
Summary
Surveyor observations and staff interviews revealed multiple failures in the facility's medication management practices. On one occasion, a medicine cup containing a Tylenol tablet was left unattended on top of a medication cart in the hallway, with the Certified Medication Technician admitting to dispensing the medication and leaving it out instead of discarding it. Additional observations of medication carts found opened Lantus insulin pens and a Breo Ellipta inhaler without dates, as well as an expired Lantus insulin pen and an opened Active Liquid Protein container without a date, all contrary to manufacturer instructions and facility policy. Staff acknowledged these items were either expired or not properly dated when opened. Further deficiencies were identified in medication rooms, where surveyors found bottles of Kayexalate and a box of Lovenox injections prescribed for residents no longer on the unit, which had not been placed in the discarded medication bin as required. Refrigerators in medication rooms contained an opened Lispro insulin pen without a date and a bottle of Lorazepam Intensol that was expired. Staff interviews confirmed awareness that these medications were either expired, not dated, or should have been discarded, but had not been managed according to policy and professional standards.
Failure to Implement Enhanced Barrier Precautions for Residents with Wounds and Catheters
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling urinary catheters. Surveyor observations revealed that residents with open wounds and a urinary catheter did not have the required EBP signage posted on their room doors, as mandated by facility policy and CDC guidance. Record reviews confirmed that these residents had physician orders for wound care and catheter management, which should have triggered EBP implementation, including the use of gowns and gloves during high-contact care activities. Interviews with nursing assistants and the unit manager indicated a lack of awareness and training regarding EBP requirements. Staff members providing direct care to affected residents were unaware that EBP and PPE use were necessary, and the unit manager acknowledged the absence of appropriate signage. The clinical market advisor also confirmed the expectation that residents with wounds or indwelling devices should be on EBP, with staff utilizing PPE during care. These findings demonstrate that the facility did not follow its own procedures or ensure staff competency in infection control practices for residents at increased risk of infection.
Failure to Provide Resident-Preferred Activities During Power Outage
Penalty
Summary
The facility failed to provide an ongoing program of activities that supported residents' choices and preferences, as identified in their comprehensive assessments and care plans, for three residents who were unable to watch television in their rooms from 5/9/2025 through 5/13/2025. All three residents had care plans and MDS assessments indicating that watching television and keeping up with the news were important or somewhat important to them. Despite this, their televisions were nonfunctional due to a power outage affecting their room outlets, and no alternative means were provided for them to engage in their preferred activities. Resident interviews revealed that each resident was dissatisfied and upset about being unable to watch television or movies, particularly over the weekend when no other activities were available. The Maintenance Director confirmed awareness of the power outage affecting the outlets, and the Clinical Market Advisor stated that it was expected that affected residents should have been offered tablets to watch television or movies, but this was not done. The lack of timely intervention resulted in the residents being left without meaningful activities aligned with their preferences for several days.
Failure to Provide Consistent Pressure Ulcer Prevention and Assessment
Penalty
Summary
A resident with a history of right femur fracture, osteoarthritis, and non-ambulatory status was identified as being at risk for skin breakdown upon admission. The resident's care plan included interventions such as providing preventative skin care as ordered and conducting weekly skin checks by a licensed nurse. However, documentation revealed that staff failed to provide preventative skin care for 32 out of 36 opportunities in May, and weekly skin assessments were not completed after the initial assessment on 5/1/2025. Interviews with staff confirmed the lack of ongoing skin assessments and preventative care as outlined in the care plan. During interviews and direct observation, the resident reported having bed sores on the buttocks, and staff observed pink, blanchable areas on both buttock cheeks. The facility's wound nurse and Assistant Director of Nursing acknowledged that residents with impaired mobility and a history of pressure injuries require preventative skin care and regular assessments, but could not provide evidence that these interventions were consistently implemented for this resident. The failure to follow the care plan and professional standards of practice led to the deficiency in pressure ulcer prevention and care.
Failure to Address Significant Weight Loss and Notify Clinical Staff
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident who experienced a significant weight loss. According to the facility's own policy, licensed nurses are required to monitor and document weights, review significant weight changes, and notify the physician and dietitian when such changes occur. The resident, admitted with diagnoses including sepsis and diabetes mellitus, was identified as being at nutritional risk and had a physician's order for weekly weights. Despite this, the resident experienced a 6.7% weight loss over a short period, with weights documented almost daily showing a consistent decline. There was no evidence in the record that any nutritional intervention was implemented in response to the weight loss. Interviews with the Registered Dietitian and the resident's physician revealed that neither was aware of the significant weight loss, and the dietitian stated she would have intervened if notified. The Assistant Director of Nursing confirmed that the facility's computer system is designed to trigger alerts for significant weight loss, which should prompt a reweigh and further assessment, but this process was not followed for the resident in question.
Failure to Document and Monitor PICC Line Care for Resident Receiving IV Antibiotics
Penalty
Summary
The facility failed to adhere to professional standards of practice for the administration and monitoring of intravenous (IV) therapy for a resident with a peripherally inserted central catheter (PICC) who was receiving IV antibiotics for enterococcal bacteremia. The resident was admitted with a PICC line in place and had physician orders for regular dressing changes, as well as for documentation of the external catheter length and upper arm circumference, with instructions to notify the practitioner if the catheter length changed. However, the hospital transfer documentation did not include the required initial measurements, and subsequent facility records did not show evidence that these measurements were ever obtained or documented. Medication Administration Records indicated that PICC line dressing changes were signed off as completed by a registered nurse on two occasions, but during interviews, the nurse admitted to signing off in error and stated she had never performed the dressing changes. Additionally, there was no documentation of the required measurements on the dates dressing changes were recorded. Observations confirmed discrepancies in the dressing change dates and staff involved. Facility leadership and clinical staff were unable to provide evidence that the necessary monitoring and documentation for the PICC line had been completed as ordered.
Failure to Monitor Dialysis Access Site per Policy and Care Plan
Penalty
Summary
A resident with end stage renal disease and dependence on renal dialysis was admitted to the facility in April 2023. The facility's policy required licensed nurses to check the dialysis access site for patency by auscultating for a bruit and palpating for a thrill before and after dialysis and every shift. The resident's care plan also included an intervention to monitor the dialysis access site for a positive bruit and thrill every shift and as needed. However, there was no evidence in the medical record of a physician's order to perform these assessments as required by the facility's policy and the resident's care plan. Additionally, documentation review showed that the last recorded assessment of the dialysis site for bruit and thrill occurred on 9/21/2024, with no subsequent assessments documented until the issue was identified by surveyors. Staff interviews confirmed the absence of an order to monitor the dialysis access site as per policy, and the order was only obtained after the surveyor brought the concern to the facility's attention. This failure resulted in the resident not receiving dialysis access site monitoring consistent with professional standards of practice and the comprehensive person-centered care plan.
Failure to Act on Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that irregularities identified by the Clinical Consultant Pharmacist during the monthly Medication Regimen Review (MRR) were reviewed and acted upon by the residents' providers for three of six residents reviewed. For one resident, the pharmacist recommended decreasing the Lantus insulin dose and evaluating the Sitagliptin dose, as it exceeded the manufacturer's maximum recommended amount. For another resident, the pharmacist recommended evaluating the continued need for lorazepam, reviewing the diagnosis and usage pattern, and either discontinuing the order or specifying the duration for the PRN order. For a third resident, the pharmacist identified duplicate PRN orders for phenazopyridine, recommended clarifying acetaminophen dosing to not exceed 3 grams daily, and suggested specifying the amount of fluid to mix with Miralax. Record review did not reveal evidence that these recommendations were reviewed or acted upon by the residents' providers. During an interview, facility leadership was unable to provide documentation that the pharmacy consultation reports were reviewed and addressed as required by facility policy and procedure.
Failure to Administer Prescribed Warfarin Doses
Penalty
Summary
A deficiency occurred when a resident receiving Warfarin therapy did not receive prescribed doses of the medication on two consecutive days. The resident, who had a history of atrial fibrillation, hypertension, and a cardiac pacemaker, was admitted with physician orders for specific Warfarin dosing and regular PT/INR monitoring. Documentation showed that the resident's PT/INR was within the therapeutic range prior to the missed doses, and the physician had ordered continuation of the Warfarin regimen with follow-up lab testing. However, review of the Medication Administration Record (MAR) revealed that the resident did not receive Warfarin on the specified dates, and there was no evidence of a Warfarin order being implemented on one of those days. Subsequently, the resident's PT/INR dropped below the therapeutic range, as confirmed by lab results. The Assistant Director of Nurses acknowledged during interview that the resident missed the Warfarin doses on the identified dates.
Improper Disposal of Garbage and Refuse in Dumpster Area
Penalty
Summary
Surveyor observation of the facility's outside dumpster area, in the presence of the Food Service Director, revealed improper disposal of garbage and refuse. Various items, including broken down cardboard boxes, used surgical and N95 masks, a tall cardboard box containing wood wall baseboard pieces, used bubble wrap, a mattress, five pieces of wood, and a large metal bed frame, were found scattered on the ground surrounding the dumpster. During an interview, the Maintenance Director acknowledged the presence of these items and confirmed that the area needed to be cleaned and the items discarded.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish and implement an effective Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program, as required. Specifically, the facility did not ensure that antibiotic use protocols were followed for two residents. According to the CDC and the facility's own policy, antibiotic stewardship should include standardized practices for evaluating residents suspected of infection, optimizing diagnostic testing, and conducting antibiotic reviews or 'time-outs' after antibiotics are initiated. The facility reported using the McGeer’s Criteria for identifying infections, which requires specific clinical and laboratory findings before starting antibiotics for residents with indwelling catheters. For one resident with a history of nontraumatic intracerebral hemorrhage and an indwelling catheter, a physician ordered Bactrim DS for a possible urinary tract infection after the catheter was changed and purulent urine was observed. Although diagnostic tests were ordered, there was no evidence that an antibiotic review or time-out was completed after the antibiotic was started, as required by the facility’s policy and CDC guidelines. This omission was acknowledged by facility leadership during the survey. For another resident with atrial fibrillation and an indwelling catheter, ceftriaxone was started for a suspected urinary tract infection following episodes of hematuria. However, there was no evidence that the resident met the McGeer’s Criteria prior to starting the antibiotic, and subsequent urine culture results showed no bacterial growth. Facility staff were unable to provide documentation that the antibiotic stewardship program was followed in this case, as required by policy.
Failure to Immediately Notify Resident's Representative After Fall and Hospital Transfer
Penalty
Summary
The facility failed to immediately notify a resident's representative following an accident that resulted in injury and required transfer to an acute care hospital. According to the facility's policy, immediate notification of the patient, physician, and representative is required in the event of an accident resulting in injury and a decision to transfer the patient. Record review showed that the resident, who had a history of stroke, sustained a fall resulting in a laceration above the left eye that required sutures. Documentation indicated that the name of the family or representative notified was listed as unknown shortly after the incident. Further review of records did not provide evidence that the resident's representative was informed immediately of the accident and subsequent hospital transfer. During an interview, the Assistant Director of Nursing Services was unable to provide proof that the required notification occurred. The lack of timely communication with the resident's representative following the incident constituted a deficiency in meeting regulatory requirements.
Failure to Complete and Document Post-Fall Neurological Assessments
Penalty
Summary
The facility failed to meet professional standards of quality by not completing required neurological assessments for two residents following falls, as identified through record review and staff interviews. For one resident with a history of stroke who sustained a fall resulting in a head laceration and required sutures, there was no evidence that the facility's neurological assessment protocol was initiated after the resident returned from the emergency room, despite provider recommendations and facility policy requiring such assessments for head injuries or unwitnessed falls. The Assistant Director of Nursing was unable to provide documentation that the neuro checks were completed as required. For another resident with dementia who experienced an unwitnessed fall, the facility's neurological evaluation flow sheet indicated that assessments were to be performed at specific intervals following the incident. However, documentation was missing for all required assessment times within the first two hours post-fall. The Assistant Director of Nursing confirmed that the neurological evaluation was not completed in its entirety and acknowledged that staff did not document the assessments as expected per facility policy.
Failure to Monitor and Document Nutritional Status
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable nutritional status, as evidenced by significant weight fluctuations that were not properly addressed. The resident, who was readmitted with serious medical conditions including brain cancer and difficulty swallowing, experienced a 9.2% weight loss upon readmission, followed by an 8.72% weight gain, and then a 6.42% weight loss. Despite these significant changes, there was no evidence that the resident was re-weighed to confirm the accuracy of these measurements, as required by the facility's policy. Interviews with staff, including a registered nurse and the dietitian, confirmed that the resident should have been re-weighed after each significant weight change. Additionally, there was incomplete documentation of the resident's meal and snack intake over a two-week period, with several days lacking any recorded intake. The dietitian was not notified of the significant weight loss, which would have prompted a nutritional intervention. Interviews with the speech therapist and nursing assistant revealed that meal intakes were supposed to be documented in the electronic record, but this was not consistently done. The Director of Nursing Services acknowledged the lack of re-weighing and incomplete meal documentation, which were contrary to the facility's policies.
Failure to Honor Resident's DNR Order
Penalty
Summary
The facility failed to honor a resident's Advanced Directive, specifically a Medical Orders for Life Sustaining Treatment (MOLST) form, which indicated a Do Not Resuscitate (DNR) order. The resident, who was readmitted to the facility with conditions including Atrial Fibrillation, acute osteomyelitis of the left hand, and diabetes, passed away within 24 hours of admission. Despite the MOLST form being signed by a Nurse Practitioner and completed with the resident's next of kin, staff initiated cardiopulmonary resuscitation (CPR) and used a defibrillator when the resident was found unresponsive. During the surveyor's interview with the Assistant Director of Nursing Services (ADNS), it was acknowledged that the resident had a DNR order, and the staff should not have performed CPR. The incident was reported to the Rhode Island Department of Health, and the ADNS confirmed the oversight in following the resident's MOLST form, which clearly stated the resident's wish to allow natural death without resuscitation efforts.
Incomplete Wound Care Orders for Resident
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for a resident with a wound care need. The resident was admitted with diagnoses including bacteremia, a methicillin susceptible staphylococcus infection, and a Stage IV pressure injury to the left ischium. A hospital document indicated that the wound required treatment with Dakins 0.125% and packing with a wet to dry dressing twice daily and as needed. However, the physician's order dated four days after admission only included the application of Sodium Hypochlorite Solution 0.125% twice daily, without instructions for wound packing or specifying the wound location. The Treatment Administration Records for June and July 2024 showed that the treatment was signed off as administered, despite the incomplete order. During an interview, the Director of Nursing Services acknowledged the deficiency, noting that the wound treatment order lacked necessary details for wound packing and the specific area for treatment application. This oversight indicates a failure to transcribe a complete and accurate order for the resident's wound care, as expected by professional standards.
Unnecessary Drug Administration Due to Transcription Error
Penalty
Summary
The facility failed to ensure a resident's drug regimen was free from unnecessary drugs, as evidenced by the administration of additional doses of an antibiotic beyond the prescribed amount. The resident, who was admitted in June 2024 with diagnoses including bacteremia, methicillin susceptible staphylococcus infection, and osteomyelitis, was ordered to receive Meropenem intravenously for 49 doses. However, the Medication Administration Record for July 2024 showed that the resident received four extra doses of Meropenem beyond the ordered 49 doses. These additional doses were administered on July 15 and July 16, 2024. During an interview, the Director of Nursing Services acknowledged the error and explained that the resident had missed two doses on July 2 and July 5, 2024. The nurse responsible for transcribing the missed doses to be added to the order entered the end date incorrectly, leading to the administration of the extra doses.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and distributed in accordance with professional standards for food service safety, as observed by surveyors in the main kitchen and three kitchenettes. During the initial tour of the kitchen, a large package of hot dogs was found opened, with no label or date, which was acknowledged by the Food Service Director (FSD). Additionally, a document on the refrigerator door in the main dining area instructed staff to label all resident food items with their name and date, yet several items, including a Styrofoam cup of milk and a bagel, were found unlabeled and undated. Staff G confirmed these items should have been discarded per facility policy. Further observations in the transitional care unit and Homestead unit kitchenettes revealed multiple expired items, including yogurt, probiotic drinks, and a jar of applesauce, as well as unlabeled containers of food. The FSD and a registered nurse acknowledged these items were expired and should have been discarded. The FSD admitted that dietary staff were responsible for maintaining the kitchenettes and that the expired and unlabeled items should have been discarded, indicating a failure to adhere to the facility's food safety policies.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to assist residents in obtaining routine dental services for two residents, identified as Resident ID #69 and Resident ID #37. Resident ID #69 was admitted in July 2020 with diagnoses including cognitive communication deficit and dysphagia. Despite a physician's order for dental consults and a progress note indicating the presence of decayed or broken teeth, there was no evidence that the resident received routine dental services since admission. Observations confirmed multiple missing teeth, and interviews with the Infection Preventionist and Director of Nursing Services revealed they could not provide evidence of dental services or resident refusals. Similarly, Resident ID #37, admitted in March 2023 with dementia and dysphagia, also did not receive routine dental services. The resident's records showed a physician's order for dental consults and a progress note highlighting decayed or broken teeth. Observations noted missing and broken teeth, and an interview with an LPN confirmed the lack of evidence for dental services. Both cases demonstrate the facility's failure to provide necessary dental care as per the residents' health needs and physician's orders.
Infection Control Deficiencies in PPE Use and Wound Care
Penalty
Summary
The facility failed to provide a safe and sanitary environment to prevent the transmission of infections, particularly in relation to Enhanced Barrier Precautions (EBP) and wound dressing changes. For Resident ID #75, a nursing assistant was observed not wearing a gown while emptying a urostomy catheter bag, despite signage indicating the requirement for gown and gloves during high-contact activities. Similarly, Resident ID #97 was assisted with bathing and toileting by a nursing assistant who did not wear a gown, contrary to the care plan's instructions for maintaining EBP. Resident ID #115, who has an indwelling Foley catheter, was also subject to improper infection control practices. A staff member was observed emptying the catheter bag without wearing a gown, as required by the EBP guidelines. The Infection Preventionist confirmed the expectation for staff to wear the appropriate PPE when caring for residents on EBP. Additionally, Resident ID #329, who has a PICC line and a wound, was cared for by staff who did not adhere to the EBP requirements, including a nurse who provided wound care without wearing a gown. Furthermore, during a wound dressing change for Resident ID #329, a nurse placed a soiled dressing on the resident's bed and applied a clean dressing with ungloved hands, failing to perform hand hygiene. This action was acknowledged by the nurse and was contrary to the expected infection control practices. The Director of Nursing Services indicated that proper hand hygiene and PPE use were expected during such procedures.
Failure to Follow Physician's Orders for Fortified Diets
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 fortified diets for two residents. Resident ID #63, who was admitted with diagnoses including unspecified protein-calorie malnutrition, dysphagia, and cognitive communication deficit, was observed not receiving the prescribed double protein portions and fortified foods during multiple meals. Despite a care plan indicating the resident was at nutritional risk and required these dietary interventions, observations on several dates confirmed the resident did not receive the ordered diet. Similarly, Resident ID #88, admitted with dementia and identified as being at nutritional risk due to weight loss, was also not provided with the fortified diet as ordered. The resident experienced a significant weight loss, and observations over several days showed the resident did not receive the fortified foods prescribed. Interviews with the Registered Dietician and the Director of Nursing Services confirmed the failure to provide the ordered diets, and no evidence was available to show compliance with the dietary orders.
Failure to Apply Hearing Aids as Ordered
Penalty
Summary
The facility failed to ensure that a resident with sensorineural hearing loss received the necessary assistive devices to maintain hearing abilities. The resident, who was readmitted to the facility in November 2022, had a care plan indicating impaired communication due to hearing loss and required assistance with hearing aids. The care plan emphasized the importance of the resident engaging in meaningful daily routines, such as listening to music and the radio. A physician's order from January 2023 instructed nursing staff to apply the resident's hearing aids every morning and remove them at bedtime. However, the Medication Administration Record for May 2024 showed that the hearing aids were applied only once during the entire month, on May 1, with 'Not Applicable' documented for the remaining days. Surveyor observations on multiple occasions in late May 2024 confirmed that the resident was not wearing hearing aids and had difficulty hearing. Interviews with the resident's family member and facility staff revealed that the hearing aids were typically applied only when the resident had visitors, contrary to the physician's order. Both the Nurse Manager and the Director of Nursing Services acknowledged the oversight, with the Director of Nursing Services expressing an expectation that staff should apply the hearing aids daily as ordered.
Failure to Provide Ankle-Foot Orthosis for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with limited range of motion, specifically in obtaining an ankle-foot orthosis (AFO) to assist with mobility. The resident, who was readmitted to the facility for a short-term rehabilitation stay, had a history of hemiplegia and hemiparesis following a stroke. The care plan included the need for an assistive device, and a physician order for an AFO was placed. However, despite the order and the resident being cast for the AFO, the device was not provided to the resident as observed by surveyors over several days. The delay in obtaining the AFO was due to a lack of follow-up by the facility's Rehabilitation Services. The orthotic company had rescheduled a visit, and the necessary physician's signature on the Detailed Prescription form was not obtained. Interviews with staff revealed a lack of clarity on the process for obtaining the physician's authorization, resulting in the resident not receiving the prescribed AFO. This oversight was acknowledged by the Director of Nursing Services, who indicated that the Rehabilitation department should have ensured the resident received the device as ordered.
Failure to Follow Bowel Protocol for Resident with Constipation
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with constipation, as identified during a survey. The resident, who was admitted with diagnoses including muscle weakness and urinary incontinence, was occasionally incontinent of bowels and dependent on staff for toileting. Despite having a care plan in place to monitor and manage gastrointestinal symptoms related to constipation, the resident reported not having a bowel movement for more than four days and having to request medications for constipation. The physician's orders included a bowel protocol with specific medications to be administered if the resident had not had a bowel movement in a specified timeframe. The record review revealed that the resident did not have a bowel movement for six days, and the facility's bowel protocol was not followed. Although Miralax was administered on one occasion, there was no evidence of further interventions or that a provider was notified of the prolonged constipation. Interviews with staff indicated a lack of communication and understanding of the bowel protocol, with assumptions that electronic systems would alert nurses. The Director of Nursing Services acknowledged the failure to initiate the bowel protocol and the lack of notification to a provider, despite the resident not having a substantial bowel movement for six days.
Failure in Dialysis Communication and Follow-Up
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received services consistent with professional standards of practice. The resident, who was admitted with end-stage renal disease and hypertension, was receiving hemodialysis three times a week at a dialysis center. A Nurse Practitioner noted the resident's elevated blood pressure and requested that nursing staff send a blood pressure log to the dialysis center for recommendations. However, the communication sheet sent to the dialysis center was left blank by the center, and there was no evidence that the facility followed up with the dialysis center or notified the physician about the lack of response. Interviews with facility staff and the dialysis center's Clinic Manager revealed that the facility did not consistently send communication sheets with the resident to the dialysis center. The Medical Director indicated that nursing should have followed up with the dialysis center and notified the physician, especially given the resident's elevated blood pressure. The Director of Nursing Services could not provide evidence of effective communication with the dialysis center or physician notification, highlighting a breakdown in the communication process necessary for managing the resident's care effectively.
Failure to Provide Required Physical Therapy Services
Penalty
Summary
The facility failed to provide specialized rehabilitation services, specifically physical therapy, as required by the comprehensive plan of care for a resident with a history of cerebral infarction, hemiplegia affecting the left dominant side, and gait and mobility abnormalities. The resident, who was admitted in January 2023, expressed a desire for more therapy to aid mobility. The Minimum Data Set (MDS) assessment indicated the resident had intact cognition but required total dependence for bed mobility and transfer. An Occupational Therapy screen conducted in March 2024 identified functional impairments and requested a physical therapy evaluation, which was not completed. Interviews with the Director of Rehabilitation Services and the Director of Nursing Services confirmed the expectation that the physical therapy evaluation should have been completed following the request. However, neither could provide evidence of its completion. Staff I, the Occupational Therapist, noted the resident's hip tightness and discomfort in the wheelchair, emphasizing the need for physical therapy to assist with positioning and seating. The lack of a completed physical therapy evaluation represents a failure to adhere to the resident's care plan, resulting in unmet rehabilitation needs.
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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