Harris Health Center Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in East Providence, Rhode Island.
- Location
- 833 Broadway, East Providence, Rhode Island 02914
- CMS Provider Number
- 415098
- Inspections on file
- 23
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Harris Health Center Llc during CMS and state inspections, most recent first.
Surveyors found that food service operations did not meet professional standards in the main kitchen and a kitchenette. An ice machine contained visible pink residue on an internal component, and a worktable used at times for food preparation held a cell phone and beverage cups. One freezer contained a resident-labeled frozen chicken breast with heavy ice accumulation and multiple expired cream products, and the same freezer had damaged door molding with black buildup and a flaking interior finish. In the kitchenette refrigerator, surveyors observed an unlabeled, undated cup with white liquid and a brown bag labeled only with a resident’s name that held multiple food items, including unidentifiable cubed food with a patchy white film, all lacking required labeling, dating, and discard information per facility policy.
The facility failed to follow its own policy requiring informed consent and documentation before initiating or changing psychotropic medications for three residents with dementia, Alzheimer’s disease, and schizoaffective disorder. Records showed multiple psychotropic drugs and dose changes, including Rexulti, Seroquel, Trazodone, Mirtazapine, and Memantine, without evidence that residents or their representatives were informed in advance of new medications or dosage increases, or that risks, benefits, side effects, and treatment alternatives were explained. Documentation also lacked evidence that nonpharmacological interventions were attempted before starting these psychotropic therapies, despite expectations stated by the physician and DON.
The facility failed to document required monitoring for effectiveness and side effects of psychotropic medications for several residents with conditions such as schizoaffective disorder, dementia, Alzheimer’s disease, major depressive disorder, and bipolar disorder. Although care plans and facility policy called for monitoring of mood/behavior, adverse effects, and medication effectiveness, clinical records for these residents did not contain such documentation despite multiple psychotropic prescriptions. In interviews, the physician stated that staff should continuously monitor behaviors and attempt nonpharmacological interventions before initiating psychotropic therapy, while an RN acknowledged there was no system for behavior documentation and the DON could not demonstrate that monitoring was completed as expected.
A resident with dementia and severe cognitive impairment, care-planned for sexually inappropriate behavior and to be seated away from the opposite gender, was instead seated between two residents of the opposite gender in a community room while two staff members were present. Another cognitively impaired resident with behavioral disturbances struck this resident in the eye and forehead, causing a laceration and a bleeding scratch. Staff interviews confirmed that the two residents were known not to get along and that the resident with sexually inappropriate behaviors was supposed to be kept away from the opposite gender, yet the DON and Administrator could not provide evidence that this care plan intervention was followed or that the resident was kept free from physical abuse.
A resident with a history including acute respiratory failure with hypoxia was readmitted to the facility and later had an unplanned discharge to an acute care hospital, with return to the facility anticipated. Facility policy, as outlined in a document titled “RESIDENT BED HOLD NOTICE,” requires that residents and/or their representatives be informed of the bed-hold policy whenever a resident is transferred for hospitalization. Record review showed no written notice of the bed-hold policy was provided to the resident at the time of transfer, and the Social Worker could not produce documentation that such written notification occurred. This failure to provide written notice of the bed-hold policy at the time of hospital transfer resulted in the cited deficiency.
A resident admitted with hypo-osmolality and hyponatremia had physician orders for thin liquids with no free water and a regular diet with a fluid restriction. Surveyors found that these fluid restriction orders, in place since admission, were not incorporated into a comprehensive, person-centered care plan with measurable objectives and timeframes. During interview, the DON acknowledged that she would have expected the fluid restriction order to be included in the resident’s comprehensive care plan.
The facility failed to involve a resident’s court‑appointed guardian in ongoing care planning despite the resident having severe cognitive impairment and the guardian being listed as the primary representative, with no evidence of invitations or attempts to include the guardian in multiple care conferences. In a separate issue, the facility did not follow an existing care plan for a resident with dementia and sexually inappropriate behaviors, as the resident was seated between residents of the opposite gender in the dining room and staff did not intervene, leading to a resident‑to‑resident altercation. Additionally, the care plan for the resident who struck another resident, who had dementia with mood and behavioral disturbance and psychosis, was not revised by the IDT to include interventions related to the abuse incident, contrary to facility policy and expectations stated by the DON.
Surveyors found that staff did not consistently follow physician orders or professional standards in several cases. A resident with dementia never had an ordered urine culture obtained, and there was no documentation that the provider was notified when staff were unable to collect the specimen. A resident with a suprapubic catheter, ordered for Enhanced Barrier Precautions, received personal care from a CNA who did not wear a gown despite posted EBP signage. Two residents experienced repeated missed or refused doses of ordered medications, including gabapentin, eye lubricants, and hydroxyzine, without evidence that a nurse or provider was notified or that the issues were addressed. Another resident on a fluid restriction for hyponatremia had orders that did not specify the allowed fluid amount, and the record showed that, although the MD was contacted about unclear limitations, the order was never clarified and staff could not state the specific restriction.
Surveyors found that medications on a first-floor CMT medication cart were not stored and labeled according to the facility’s MASP policy and manufacturer guidelines. Two Wixela inhalers and one fluticasone propionate inhaler were out of their foil pouches, with one Wixela lacking an open-date label and the others labeled with open dates that exceeded manufacturer-recommended discard timeframes. An opened bottle of house-stock Allergy Relief (fexofenadine 180 mg), used for a resident, was present without a visible expiration date. The CMT acknowledged the issues, and the DON could not provide evidence that medication storage and labeling complied with facility policy and professional standards.
A resident with a history of food in the respiratory tract and an MDS indicating a need for partial/moderate assistance with eating had a physician’s order for staff to assist with meals at all times on day and evening shifts. Surveyors observed the resident eating independently in a common area without staff assistance during midday meals, while the Treatment Administration Record showed the ordered meal assistance as completed for those shifts. An RN acknowledged documenting the order as completed even though he did not assist the resident, had delegated the task to NAs, and did not know whether any NA had actually provided meal assistance. The DON stated she expected staff to follow physician orders and document accurately.
Surveyors found that the facility did not conduct required antibiotic “time outs” for two residents receiving antibiotic therapy. One resident with pneumonia, acute respiratory disease, and dysphagia received topical mupirocin to a toe wound without any documented day 2–3 antibiotic review. Another resident with pneumonia, acute respiratory failure, epilepsy, and repeated falls received azithromycin and ceftriaxone, again with no evidence of a day 2–3 antibiotic review. The DON could not provide documentation of antibiotic time outs and reported being unfamiliar with the antibiotic timeout process.
The facility did not complete a compliant facility-wide assessment to determine needed resources for competent resident care during routine operations and emergencies. The documented Facility Assessment, last updated in late 2025, listed the Administrator, DON, Social Worker, Medical Director, and a resident as participants, but there was no evidence that input from a resident representative or family members was solicited or considered, as required. During a surveyor interview, the Administrator could not provide proof of such input and acknowledged he was unaware that including a resident representative or family member was required.
A resident with a history of bipolar disorder and epilepsy, assessed as having intact cognition and independent ambulation, exited the facility without following the LOA policy by accessing an unsecured key at the staff desk and unlocking a rear door. Staff failed to complete the LOA log and did not notice the resident's absence until notified by police, resulting in a failure to provide adequate supervision and prevent elopement.
A resident experienced significant weight fluctuations, but the facility failed to re-weigh or notify the physician, dietician, and DNS as required by policy. The resident, at nutritional risk due to dysphagia, showed weight changes of up to 19 pounds in a week without documented follow-up actions.
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential safety hazards for residents. Three residents with various medical conditions were observed using bed rails without documented entrapment assessments. The Director of Nursing could not provide evidence of completed assessments, indicating a lapse in the facility's maintenance program.
A resident with schizoaffective disorder experienced falls without a comprehensive care plan in place. Despite the facility's Fall Prevention Program requirements, no fall-related care plan was developed after the resident's falls. Staff interviews confirmed the lack of a care plan addressing the resident's fall risk.
The facility failed to conduct quarterly fall assessments for two residents as ordered and did not notify the physician of psychiatric recommendations for two residents. One resident with dementia and major depressive disorder did not have a fall assessment since December 2023, and another with polyarthritis and a history of falling missed a June 2024 assessment. Additionally, psychiatric recommendations for Quetiapine and melatonin were not communicated to the physician.
Surveyors found deficiencies in medication storage and labeling, including expired Fluzone vaccines and undated opened medications like Latanoprost Solution and inhalers. Staff acknowledged these issues, which were observed in the medication storage room and cart.
Food Storage, Labeling, and Equipment Sanitation Deficiencies in Dietary Areas
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards in the main kitchen, a kitchenette, and related equipment. During an initial kitchen tour, the interior of the ice machine contained a white component with small flecks of pink, wipeable matter that could be removed with a paper towel, and the cook acknowledged this residue. On the same tour, a worktable that is occasionally used as a food preparation area had a cell phone and two beverage cups lying on it, which the cook acknowledged should not have been there. In one of three freezers, surveyors found a large zip-lock style bag labeled with a resident’s name and dated “7/21” containing a frozen chicken breast with an accumulation of ice crystals, and seven unopened containers of Rich’s On Top Soft Whip Sweet Cream with an expiration date of 9/19/2025; the cook acknowledged the products were expired and that the chicken breast should have been discarded earlier. The same freezer had a door with rubber molding partially hanging off, with an accumulation of black matter and food particles behind the molding, and the interior white-coated finish was scored, discolored, and flaking off in various locations, which the cook also acknowledged. In the kitchenette refrigerator, surveyors observed an unlabeled and undated eight-ounce Styrofoam cup filled with a white liquid, which the cook acknowledged should have been labeled, dated, and discarded. They also found a brown bag labeled only with a resident’s name that contained three individually wrapped cheese sticks, an opened bag of pepperoni, an unlabeled and undated zip-lock style bag containing a pickle, and an unlabeled and undated plastic container with unidentifiable cubed red and white food items covered with a patchy white film. The brown bag lacked a room number, a received-on date, and a discard-by date, contrary to the facility’s policy on food brought in by visitors, which requires nursing staff to monitor such food for spoilage, contamination, and safety, and to label it with the resident’s name, room number, and date, and discard after 24 hours. The cook acknowledged the lack of labeling and dating and the presence of the patchy white film on the food items.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent and to provide required information to residents or their representatives before initiating or changing psychotropic medications, as required by facility policy. The policy states that all psychotropic medications require resident or representative consent, including awareness of the medication, side effects (including black box warnings when applicable), and risk/benefit information, and that consent must be obtained prior to administration. The policy also requires that residents or representatives be informed of any new medications or dosage increases and that progress notes show evidence of this notification, as well as that nonpharmacological interventions be attempted before obtaining an order for a psychotropic medication. For one resident with dementia and severe cognitive impairment, record review showed multiple psychotropic medications and dose increases, including Rexulti at various dosages, Trazodone, and Memantine. The clinical record lacked evidence that the resident’s representative was informed in advance of the addition of new psychotropic medications or dosage increases, and there was no documentation that the representative was informed of risks, benefits, side effects, or treatment alternatives. The record also did not show that nonpharmacological interventions were attempted prior to initiating these psychotropic therapies. In an interview, the resident’s primary representative stated they were unaware of the additions and dose increases and would have expected to be notified. For another resident with Alzheimer’s disease and severe cognitive impairment, the record showed prescriptions for Seroquel, Trazodone, and Mirtazapine, but there was no evidence that the resident’s representative was informed in advance of the addition of these psychotropic medications, nor that risks, benefits, side effects, or alternatives were discussed. Similarly, for a resident with schizoaffective disorder, the provider ordered Seroquel as needed for sleep, and the medication was administered on two occasions; however, the record did not show that the resident was informed in advance of this addition to the regimen or of associated risks, benefits, side effects, or alternatives, and there was no documentation of attempted nonpharmacological interventions prior to prescribing the PRN Seroquel. In interviews, the physician stated that staff are expected to attempt nonpharmacological interventions before drug therapy, and the DON stated that residents or representatives should be informed of risks, benefits, and side effects of psychotropic medications, but she was unable to provide evidence that such interventions or notifications occurred for the cited residents.
Failure to Monitor Psychotropic Medications for Effectiveness and Side Effects
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate monitoring for effectiveness and side effects of psychotropic medications for multiple residents. The facility’s own policy on Medication Administration Safety; Psychotropic Medications and New Medication Orders requires that nonpharmacological interventions be attempted before psychotropic medications are ordered, and that new medications be monitored for effectiveness and side effects, with systems in place for re-evaluation by the IDT and care plan interventions addressing monitoring. Despite this policy, record reviews for several residents on psychotropic medications did not contain evidence of such monitoring. One resident with schizoaffective disorder was prescribed lithium carbonate and olanzapine, with a care plan directing monitoring of medication effectiveness, side effects, mood, and behaviors, yet the clinical record lacked documentation of this monitoring. Another resident with dementia was prescribed memantine, Rexulti, Seroquel, and trazodone, and had a care plan focus identifying risk for adverse effects from daily psychotropic use with an intervention to monitor mood/behavior and report adverse effects or ineffectiveness, but the record similarly lacked evidence of monitoring for effectiveness and side effects. A third resident with Alzheimer’s disease was prescribed Seroquel, trazodone, mirtazapine, and olanzapine, with a care plan intervention to monitor for changes in mood/behavior and adverse effects, but again, no documentation of such monitoring was found in the record. Additional residents were affected in the same manner. One resident with major depressive disorder was prescribed buspirone and venlafaxine, with a care plan focus on risk for adverse effects from psychotropic medications and an intervention to monitor mood/behavior and report side effects or ineffectiveness, yet the record contained no evidence of monitoring. Another resident with bipolar disorder was prescribed clozapine, divalproex, mirtazapine, and sertraline, with a care plan intervention to monitor for adverse effects and report changes, but the record also lacked documentation of monitoring for effectiveness and side effects. In interviews, the physician stated an expectation that staff continuously monitor residents’ behavior and attempt nonpharmacological interventions before starting psychotropic drugs. An RN reported there was no system in place for documenting residents’ behaviors, and the DON stated she expected behavior monitoring for psychotropic effectiveness and side effects and orders for nonpharmacological interventions prior to drug therapy, but could not show evidence that such monitoring occurred for the cited residents.
Failure to Follow Care Plan Leads to Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse by not following an existing care plan intervention to keep the resident away from members of the opposite gender. One resident with dementia and severe cognitive impairment, documented by a BIMS score of 7/15, had a care plan focus area noting increased episodes of sexually inappropriate behavior toward other residents, with an intervention to seat the resident away from residents of the opposite gender in the dining room. On the date of the incident, this resident was seated in the community room between two residents of the opposite gender, including another resident with dementia, mood and behavioral disturbance, unspecified psychosis, and a BIMS score of 1/15. Surveillance video reviewed by surveyors showed that two staff members were present in the area and did not separate the resident from residents of the opposite gender as required by the care plan. An altercation occurred in which the second resident struck the care-planned resident in the eye and forehead, causing a small laceration to the left forehead and a bleeding scratch under the right eye. A facility incident report documented that the second resident struck the first resident with a fist after the first resident allegedly attempted to touch the second resident’s genital area. A nursing assistant later stated she had been told that the first resident attempted to touch the second resident’s groin, but also reported that after facility staff reviewed the surveillance video, it was determined that no such attempt occurred. A registered nurse reported that the two residents “don’t mix” and that staff try to keep them separated, and also confirmed that the resident with sexually inappropriate behaviors was to be kept away from residents of the opposite gender for a long time. The DNS and Administrator were unable to provide evidence that the care plan intervention to keep the resident away from residents of the opposite gender was followed, and the Administrator could not provide evidence that the resident was kept free from physical abuse.
Failure to Provide Written Bed-Hold Notice at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide a hospitalized resident with written notice of its bed-hold policy at the time of transfer. The facility’s undated document titled “RESIDENT BED HOLD NOTICE” states that whenever a resident is transferred for hospitalization, the resident and/or representative must be informed of the facility’s policy concerning holding the bed. Record review showed that the resident, who had been readmitted in November 2025 with diagnoses including acute respiratory failure with hypoxia, experienced an unplanned discharge and transfer to an acute care hospital on 1/3/2026, with an anticipated return to the facility. Further review of the clinical record did not reveal any evidence that written notice of the bed-hold policy was provided to the resident at the time of this transfer. In an interview on 1/30/2026, the Social Worker was unable to provide documentation that the resident had been notified in writing of the bed-hold policy when transferred on 1/3/2026. This lack of written notification at the time of hospital transfer for a resident expected to return constitutes the identified deficiency.
Failure to Incorporate Fluid Restriction Orders into Comprehensive Care Plan
Penalty
Summary
Surveyors identified that the facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident who had a physician’s order for fluid restriction. The resident was admitted in October 2025 with diagnoses including hypo-osmolality and hyponatremia, a condition characterized by excess body water relative to sodium. Record review showed dietary physician’s orders starting 10/14/2025 specifying thin liquids with no free water due to fluid restriction and a regular texture diet with a fluid restriction with meals. Further review of the clinical record did not reveal any evidence that these fluid restriction orders were incorporated into the resident’s comprehensive care plan. In an interview, the Director of Nursing Services stated she would have expected the physician’s order for the fluid restriction to be included in the resident’s comprehensive care plan. This deficiency was cited for 1 of 1 residents reviewed who had a physician’s order for a fluid restriction, as the facility did not ensure that the resident’s medical, nursing, and psychosocial needs related to fluid restriction were addressed through a comprehensive care plan.
Failure to Involve Guardian in Care Planning and to Revise Care Plans After Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s court‑appointed guardian was invited to and allowed to participate in the care planning process, and the failure to review and revise comprehensive care plans after a resident‑to‑resident abuse incident. One resident with Alzheimer’s disease, severely impaired cognition as evidenced by a Brief Interview for Mental Status score of 3/15, and a legally appointed guardian was readmitted in December 2024. Record review showed quarterly care conferences held on four dates in 2025, with documentation that the guardian participated in only the first conference. The guardian reported not being invited to any meetings to discuss the resident’s care for over a year, and the Social Worker was unable to provide evidence of attempts to notify or involve the guardian in the subsequent three care conferences, limiting the guardian’s ability to participate in development, review, and revision of the resident’s person‑centered care plans. The deficiency also includes the facility’s failure to follow its abuse prohibition policy requiring that staff interventions be carried out and included in the resident’s care plan, and to revise care plans after a resident‑to‑resident abuse incident. One resident with dementia had a care plan initiated in December 2024 for increased episodes of sexually inappropriate behavior toward other residents, with an intervention to seat the resident away from residents of the opposite gender in the dining room. Video footage from November 2025 showed this resident seated between two residents of the opposite gender, including the resident who later struck the resident, while two staff members present did not intervene to follow the seating intervention. Another resident, readmitted with dementia with mood and behavioral disturbance and unspecified psychosis, had a care plan problem indicating mood‑related resident‑to‑resident incidents, but record review did not show that the care plan was revised to include interventions specific to the November 2025 resident‑to‑resident abuse incident. The DNS stated she would have expected the care plan to be updated with new interventions.
Failure to Follow Physician Orders for Labs, Infection Control, Medications, and Fluid Restriction
Penalty
Summary
The deficiency involves multiple failures to follow physician orders and professional standards of quality for several residents. One resident with dementia had increased agitation and confusion, prompting the provider to order blood work and a urine specimen for culture and analysis. Progress notes documented that the resident refused to provide a urine sample on one date and that staff were unable to obtain the specimen on another date, but the record contained no evidence that the urine specimen was ever obtained or that the provider was notified of the inability to obtain it. The resident’s physician later stated he did not recall being informed and would have expected notification, and the DNS also stated she would have expected the specimen to be obtained as ordered or the provider to be notified with documentation. Another resident with neuromuscular bladder dysfunction and a suprapubic catheter had a care plan and physician order requiring Enhanced Barrier Precautions (EBP) every shift, including use of gown and gloves for high-contact care such as personal hygiene. EBP signage on the resident’s door instructed staff to wear a gown and gloves for activities like dressing, bathing, hygiene, and changing briefs. A surveyor observed a nursing assistant in the resident’s room adjusting bed linens while wearing only one glove and no gown, and the assistant reported she had just completed personal care without a gown despite acknowledging the EBP signage, stating she had been told a gown was not required. The Infection Preventionist stated she would have expected staff to wear a gown when assisting with the resident’s personal care. Additional deficiencies involved medication management and fluid restriction orders. One resident with stroke and seizures had physician orders for gabapentin and two eye medications, but the MAR showed frequent refusals of all three medications over many days, with no documentation that a provider was notified of these ongoing refusals. A medication technician stated the resident often refused medications and that she simply marked them as refused, without indicating that she notified a nurse or provider, while the DNS stated she would have expected such refusals to be communicated and documented. Another resident with dementia had an order for hydroxyzine pamoate three times daily, but the MAR showed multiple missed doses on several days without evidence that the provider was notified or that the doses were given, and the DNS could not provide evidence the medication was administered as ordered. A further resident admitted with hypo-osmolality and hyponatremia had dietary orders for thin liquids with no free water due to a fluid restriction and a regular diet with a fluid restriction, but the record did not specify the amount of fluid allowed. A progress note documented that the MD was contacted because information about the limitation was unclear and that it was due to low sodium, yet there was no evidence the order was clarified, and both a medication technician and the physician later confirmed that the specifics of the restriction were not defined in the order.
Improper Storage and Labeling of Medications on Medication Cart
Penalty
Summary
Surveyors identified a failure to store and label medications according to professional standards and the facility’s own Medication Administration Safety Program (MASP) policy on one of three medication carts reviewed. The policy requires periodic checks for expired medications, prohibits altering labels except to note the date opened, and mandates that inhalers be labeled and stored per manufacturer guidelines. During observation of the first-floor CMT medication cart with the CMT present, surveyors found a Wixela inhalation device out of its foil package with a dose counter of 57 that was not labeled with the date it was opened, and another Wixela device out of its foil pouch with a dose counter of 5 that was labeled as opened on 10/23/2025, despite manufacturer guidance that the device should be discarded one month after removal from the foil pouch or when the dose counter reaches zero. A fluticasone propionate inhalation device was also found out of its foil pouch with a dose counter of 45 and labeled as opened on 10/23/2025, even though manufacturer guidance states it should be discarded two months after opening the foil pouch or when the dose counter reaches zero. Additionally, surveyors observed one opened bottle of Allergy Relief (fexofenadine hydrochloride 180 mg) on the cart that lacked a visible expiration date. The CMT acknowledged these findings and stated that the Allergy Relief was house stock and that a resident was currently prescribed this medication. In a subsequent interview, the DON was unable to provide evidence that the facility stored and labeled drugs in accordance with the facility’s policy and accepted professional principles, confirming the deficiency in medication storage and labeling practices on the reviewed medication cart.
Inaccurate Documentation of Ordered Meal Assistance
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate medical records and to document care in accordance with professional standards for a resident with a physician’s order for assistance with meals at all times. The resident was readmitted in December 2021 with a diagnosis that included food in the respiratory tract causing injury. A Minimum Data Set assessment dated in January 2026 indicated the resident required partial/moderate assistance of one staff member for eating. A physician’s order dated 11/25/2025 directed staff to assist the resident with meals at all times, twice daily, during the 7:00 AM–3:00 PM and 3:00 PM–11:00 PM shifts. Surveyors observed the resident eating independently in a common area without staff assistance on two separate occasions during the midday meal period. Despite these observations, the January 2026 Treatment Administration Record showed the physician’s order for meal assistance as completed for the 7:00 AM–3:00 PM shift on both days. During an interview, the RN who documented completion for one of those shifts admitted he had not personally assisted the resident with eating, stated that the task was delegated to NAs, and acknowledged he did not know which NA, if any, had assisted the resident during lunch. He further acknowledged that he documented the order as completed despite being unaware whether the assistance had actually been provided. The DON stated she would expect staff to follow physician orders and document accurately in the resident’s record.
Failure to Conduct Required Antibiotic Time Outs for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement an Infection Prevention and Control Program that includes an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use, specifically the required antibiotic “time outs.” For one resident readmitted in June 2025 with diagnoses including pneumonia, acute respiratory disease, and dysphagia, physician orders directed the use of topical mupirocin 2% to the left great toe over two ordered time periods in January 2026. Record review did not show any evidence that an antibiotic time out or a review at day two or three was conducted for this mupirocin therapy. For another resident readmitted in June 2025 with diagnoses including pneumonia, acute respiratory failure, epilepsy, and repeated falls, physician orders included azithromycin 250 mg (two tablets once, then one tablet daily for four days) and ceftriaxone 1 gram daily over several days in December 2025. Additional record review failed to reveal documentation that an antibiotic time out or a day two or three review was completed for either the azithromycin or ceftriaxone. During an interview, the Director of Nursing Services was unable to provide evidence that antibiotic time outs or reviews had been completed and acknowledged being unfamiliar with the antibiotic timeout process.
Failure to Include Resident Representative and Family Input in Facility Assessment
Penalty
Summary
The facility failed to complete and document a compliant facility-wide assessment to determine the resources necessary to care for residents competently during routine operations and emergencies. Record review showed a document titled “Facility Assessment” last updated on 9/30/2025, which listed the Administrator, Director of Nursing Services, Social Worker, Medical Director, and a resident as participants in its completion. However, further review of this assessment did not show any evidence that the facility solicited or considered input from a resident representative or family members, as required by regulation. In an interview with surveyors, the Administrator was unable to provide evidence that such input had been included and stated that he was unaware that obtaining input from a resident representative or family member was a requirement. No additional resident-specific clinical information, medical history, or condition at the time of the deficiency was provided in the report.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Lax Key Security
Penalty
Summary
A deficiency occurred when a resident with a history of bipolar disorder and epilepsy, who was assessed as having intact cognition and ambulates independently, left the facility without following the leave of absence (LOA) policy. The resident had previously been identified as at risk for elopement, and the care plan included interventions such as ensuring staff awareness of the resident's wander risk and adherence to the LOA policy. Despite these interventions, the resident was able to access a key left in an accessible location at the staff desk, unlock a rear door, and exit the facility without staff knowledge. The resident traveled by bus to visit a relative at a hospital and later requested police assistance to return to the facility. Staff interviews and record reviews revealed that the LOA log was not completed as required, and the nurse on duty did not sign off on the resident's departure or return. Video surveillance confirmed the resident's actions in obtaining the key and exiting the facility. Staff acknowledged that the key remained accessible in the same location even after the incident, and the resident's unauthorized absence was only discovered when the police contacted the facility. These actions and inactions resulted in a failure to provide adequate supervision and prevent an elopement, as required by facility policy.
Failure to Monitor and Address Significant Weight Changes
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, as evidenced by significant weight fluctuations that were not addressed according to the facility's policy. The resident, who was at nutritional risk due to dysphagia and required a mechanical soft diet, experienced significant weight losses and gains over several weeks. Despite the facility's policy requiring re-weighing within 24 hours and notifying the physician, dietician, and Director of Nursing Services (DNS) of such changes, these actions were not documented or performed. The resident's weight records showed fluctuations of up to 19 pounds in a week, yet there was no evidence of re-weighing or notification to the relevant healthcare professionals. Interviews with the primary physician, DNS, and registered dietician confirmed that they were not informed of the significant weight changes, and the dietician had not assessed the resident since being hired. This lack of adherence to the facility's protocol resulted in a deficiency in maintaining the resident's nutritional status.
Failure to Conduct Regular Bed Safety Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential safety hazards for residents. Specifically, the surveyor identified that the facility did not perform entrapment assessments for three residents who were observed using bed rails. These residents included one with osteoarthritis and joint disorders, another with hemiplegia affecting the right side, and a third with spinal stenosis and a burst fracture of the T9-T10 vertebrae. The lack of documented entrapment assessments indicates a failure in the facility's maintenance program to ensure the safety of bed equipment. During the survey, observations were made over several days, noting the presence of side rails on the beds of the affected residents. Interviews with the Director of Nursing Services revealed that there was no evidence of completed entrapment assessments for these residents. This oversight suggests that the facility did not adhere to the guidelines outlined in the State Operations Manual Appendix PP, which requires routine preventive maintenance and safety checks to prevent resident entrapment.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who experienced falls. The resident, who was readmitted to the facility in December 2023 with a diagnosis of schizoaffective disorder, had documented falls on two occasions: July 9, 2024, and August 14, 2024. Despite these incidents, the facility did not create a fall-related care plan that identified preventative measures or interventions to address the resident's fall risk. The facility's Fall Prevention Program, last revised in December 2010, mandates that fall risk assessments be conducted during admission, quarterly reviews, and significant changes in condition. It also requires that a care plan be developed for residents with a history of falls or high fall risk scores. However, a review of the resident's records and interviews with staff, including a Registered Nurse and the Director of Nursing Services, confirmed the absence of such a care plan for the resident in question.
Failure to Conduct Fall Assessments and Notify Physician of Psychiatric Recommendations
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. Specifically, two residents with physician orders for quarterly fall assessments did not have these assessments completed as required. One resident, admitted in December 2011 with dementia and major depressive disorder, had a physician's order for quarterly fall assessments, but the last documented assessment was on December 26, 2023. Another resident, admitted in March 2024 with polyarthritis, fibromyalgia, muscle weakness, and a history of falling, also had a physician's order for quarterly fall assessments, but no assessment was completed in June 2024 as ordered. Additionally, the facility did not notify the physician of psychiatric recommendations for two residents. One resident, seen for agitation and behavioral disturbance, had a recommendation to restart Quetiapine, but there was no evidence that the physician was informed. Another resident, with schizophrenia and generalized anxiety disorder, had a recommendation for melatonin, but again, there was no evidence of physician notification. Interviews with the primary care physician and the psychiatric nurse practitioner confirmed these lapses, and the Director of Nursing Services acknowledged the deficiencies.
Deficiency in Medication Storage and Labeling
Penalty
Summary
The facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles. During a surveyor observation of the 1st floor medication storage room, it was found that a 10-dose box of Fluzone vaccine and a 10-dose box of High Dose Fluzone vaccine, both with 5 doses remaining, were expired. Staff A, a Registered Nurse, acknowledged the expired status of these vaccinations during an interview immediately following the observation. Additionally, during an observation of the 1st floor Certified Medication Technician medication cart, it was revealed that there were two bottles of Latanoprost Solution, an eye drop used to treat glaucoma, that were opened and undated, despite manufacturer instructions to discard them 6 weeks after opening. Furthermore, a Wixela inhaler and two Trelegy Ellipta inhalers, used to treat asthma, were also found opened and undated, contrary to manufacturer instructions to discard them after specific periods once opened. Staff A acknowledged these medications were opened and undated, and the Director of Nursing Services confirmed the expectation for staff to date medications when opened and discard them appropriately.
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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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