Hattie Ide Chaffee Home
Inspection history, citations, penalties and survey trends for this long-term care facility in East Providence, Rhode Island.
- Location
- 200 Wampanoag Trail, East Providence, Rhode Island 02915
- CMS Provider Number
- 415002
- Inspections on file
- 24
- Latest survey
- June 20, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Hattie Ide Chaffee Home during CMS and state inspections, most recent first.
Surveyors identified several deficiencies in food service safety and sanitation, including improper labeling of chemicals, lack of cleaning schedules for kitchen equipment, dietary staff not using required hair restraints, reuse of single-use containers, use of non-durable food contact surfaces, missing thaw dates on nutritional shakes, and absence of an irreversible thermometer to verify dish machine sanitization temperatures.
Two residents did not receive care in accordance with physician's orders and professional standards. One resident with chronic venous insufficiency and leg edema was observed with heels resting on a pillow instead of being offloaded as ordered. Another resident with cellulitis received a wound dressing (hydrofera blue) not prescribed by the physician, as confirmed by nursing documentation and staff interviews.
A resident with an indwelling urinary catheter was observed multiple times with the drainage bag not positioned below the bladder, contrary to the care plan and standard nursing procedures. Staff confirmed the improper placement, and the DON acknowledged the expectation for correct positioning was not met.
Surveyors observed multiple breaches in infection control practices, including a nurse failing to perform hand hygiene between glove changes during a wound dressing change, and staff entering rooms of residents on droplet and contact precautions without required PPE such as N95 masks, gowns, and gloves. Staff acknowledged these lapses, and leadership could not provide evidence that infection control protocols were consistently followed.
The facility did not ensure that several staff members, including administrative, clinical, and therapy personnel, received mandatory annual and onboarding training in key areas such as abuse prevention, infection control, dementia care, trauma-informed care, QAPI, and HIPAA, as required by the facility's assessment. This deficiency was confirmed through record review and staff interview, with no evidence provided to show completion of the required education.
A resident with severe cognitive impairment was prescribed Trazodone for hallucinations without notifying their Power of Attorney, contrary to facility policy. The resident's representative was not informed of the medication change, despite the facility's requirement to notify them of any changes in treatment. The DNS acknowledged the oversight during interviews.
A resident with a history of stroke and dysphagia was served a breakfast tray despite having an NPO order, leading to a choking incident. Staff interviews revealed a lack of awareness about the resident's dietary restrictions, resulting in the deficiency.
Two residents requiring supervision while eating were left unsupervised, with one consuming unthickened liquids against orders and the other struggling with improperly prepared meals. Staff were unaware of the supervision and dietary requirements, and care plans did not reflect these needs, placing residents at risk for harm.
The facility did not complete annual performance evaluations for its nursing assistants, as required. A review of personnel files showed that no evaluations were conducted within the last 12 months for five nursing assistants. The DON confirmed the absence of these evaluations during an interview.
The facility failed to store and distribute food according to professional standards, with surveyors finding unlabeled and expired items in the kitchen and kitchenette. Additionally, the facility lacked a required 3-bay sink for sanitizing equipment. The Food Service Director acknowledged these deficiencies.
The facility failed to maintain an effective infection prevention and control program, with deficiencies in water management, hand hygiene, and linen handling. Legionella bacteria levels were above acceptable limits, and the facility lacked a water flow assessment. Staff did not follow proper hand hygiene for a resident with C. diff, using hand sanitizer instead of soap and water. Additionally, soiled linen was improperly handled and stored, posing an infection risk.
The facility failed to notify physicians about unavailable medications for two residents and did not follow a physician's order for medication parameters for another resident with hypertension. This resulted in missed doses of Saccharomyces boulardii and improper administration of metoprolol tartrate without checking required blood pressure and heart rate parameters.
Surveyors found deficiencies in medication storage and labeling, including pre-poured medications labeled with room numbers, expired multivitamins, and improperly stored Latanoprost eye drops. In the medication storage rooms, expired Tuberculin and undated Lorazepam were found. Staff acknowledged these practices, and the DON confirmed that pre-pouring is not allowed and medications should be dated and discarded when expired.
A resident with major depressive disorder did not receive recommended Trazodone for anxiety due to a lack of communication with a physician. Despite documented recommendations and increased anxiety symptoms, staff interviews revealed no evidence of physician notification or order implementation.
A resident with dysphagia and pneumonitis was not provided with the required 1:1 feeding assistance, despite a physician's order. The resident was observed eating without supervision, and the physician admitted to not reviewing the order individually before signing. The DON expected physicians to review orders individually.
Two residents in the facility did not receive meals prepared according to their dietary needs. A resident with severe cognitive impairment and physical limitations was served whole and hard food items instead of soft, bite-sized pieces. Another resident, requiring nectar thick liquids and a pureed diet due to dysphagia, was given unthickened beverages. Staff interviews revealed a lack of adherence to dietary orders, with the DON unable to provide evidence of compliance.
Multiple Food Service Safety and Sanitation Deficiencies Identified
Penalty
Summary
Surveyor observations, record reviews, and staff interviews revealed multiple deficiencies in food storage, preparation, distribution, and service within the facility's main kitchen and two kitchenettes. Chemical containers were not properly labeled according to OSHA standards, as evidenced by a spray bottle marked only with handwritten text. The kitchen hood and screens had visible grease accumulation, and there was no documented cleaning schedule. Dietary staff were observed not wearing appropriate hair restraints or beard coverings, and the Food Service Director (FSD) could not provide evidence of compliance with these requirements. Additionally, breadcrumbs were stored in a single-use container that was being reused, and the FSD could not confirm its appropriateness for reuse. Equipment and utensils, such as a wooden butcher block and scratched lip plates, were not made of durable, nonabsorbent materials as required. Further deficiencies included the improper labeling of thawed nutritional shakes, as none of the observed products in the kitchenettes had use-by dates to indicate when they were thawed, contrary to manufacturer instructions. The FSD acknowledged this lapse. The facility also lacked an irreversible thermometer to verify that dish machine cycles reached the required sanitizing temperature, as required by the Rhode Island Food Code. These findings collectively demonstrate a failure to adhere to professional standards for food service safety and sanitation.
Failure to Follow Physician's Orders and Professional Standards of Practice
Penalty
Summary
The facility failed to ensure that residents received care in accordance with professional standards of practice and physician's orders for two residents. One resident, admitted with chronic peripheral venous insufficiency and bilateral lower extremity edema, had a physician's order to offload heels when in bed every shift. However, during multiple surveyor observations, the resident was found in bed with heels resting directly on a pillow, rather than being properly offloaded as ordered. The Director of Nursing Services confirmed that the observed positioning did not meet the physician's order. Another resident, admitted with cellulitis of the right lower extremity, had a physician's order for wound care specifying cleansing with Vashe, application of Santyl, and covering with gauze and kerlix wrap once daily. Nursing documentation and direct observation revealed that hydrofera blue, a wound dressing, was applied to the wound without a corresponding physician's order. Staff interviews confirmed the absence of an order for hydrofera blue, and the DNS acknowledged that staff are expected to review and follow physician's orders prior to performing dressing changes.
Failure to Position Catheter Drainage Bag Below Bladder
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was not provided appropriate catheter care as required by facility policy and standard nursing procedures. The resident, who had diagnoses including hemiplegia, hemiparesis, and urinary retention, had a physician's order for an indwelling catheter and a care plan specifying that the drainage bag should be positioned below the level of the bladder. Multiple surveyor observations found that the drainage bag was not visible while the resident was in bed, and upon further inspection, it was discovered that the bag was attached to the resident's leg and lying perpendicular, not below the bladder as required. Staff interviews confirmed that the drainage bag was not positioned according to the care plan and standard procedures. Both a nursing assistant and a registered nurse acknowledged that the bag was not below the bladder, and the Director of Nursing Services stated that her expectation was for the drainage bag to be placed below the bladder. These findings demonstrate that the facility failed to provide appropriate catheter care for the resident, as required by both the care plan and established nursing guidelines.
Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by multiple observed breaches in infection control practices. During a wound dressing change for a resident with functional urinary incontinence and a coccyx wound, a registered nurse did not perform hand hygiene between glove changes as required by facility policy. The nurse removed soiled gloves, failed to wash hands or use hand sanitizer, and then donned new gloves before continuing the dressing change process. The nurse acknowledged during interview that proper hand hygiene was not performed at each glove change. Additional deficiencies were observed regarding the implementation of droplet and contact precautions for residents with communicable diseases. One resident on enhanced droplet/contact precautions had signage indicating that staff should wear an N95 mask before entering the room. However, a certified medication technician entered the room without the required N95 mask and confirmed this lapse during interview. Another resident with C. diff was on contact precautions, with signage instructing staff to wear a gown and gloves. Both a dietary aide and a nursing assistant entered the resident's room without wearing the required personal protective equipment, and both acknowledged the failure to follow protocol during interviews. Interviews with the infection control preventionist and the director of nursing services confirmed that staff were expected to follow the posted infection control precautions, but there was no evidence provided that these precautions were consistently followed. The observed failures to adhere to established infection control policies and procedures contributed to the deficiency cited during the survey.
Failure to Provide Required Staff Training
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for both new and existing staff members, as evidenced by the lack of required annual and onboarding education for seven employees. Record reviews showed that staff members in various roles, including administration, certified medication technician, nursing assistants, registered nurse, and occupational therapist, did not have documentation of completed mandatory training in areas such as abuse and neglect, infection control, dementia and behavioral health management, trauma-informed care, QAPI, corporate compliance, fire safety/disaster procedures, HIPAA, and resident rights for the year 2024. The facility assessment, last updated in January 2025, outlined the necessity for such training to ensure person-centered care, but the records did not support compliance with these requirements. During an interview, the staff developer was unable to provide evidence that the identified staff members had received all required mandatory training for 2024. The deficiency was identified through both record review and staff interview, confirming that the facility did not ensure all employees received the necessary education consistent with their roles and the facility's assessment of resident needs.
Failure to Notify Resident's Representative of Medication Change
Penalty
Summary
The facility failed to inform a resident's representative about a new medication order and the resident's hallucinations, which is a violation of their policy to notify residents and their representatives of changes in medical condition or treatment. The resident, who was admitted in May 2024 with severe cognitive impairment and a history of encephalopathy and stroke, was prescribed Trazodone by a Nurse Practitioner after experiencing hallucinations. However, there was no documentation that the resident's Power of Attorney was informed about this new medication or the hallucinations. The facility's policy requires that the resident, attending physician, and the resident's representative be promptly notified of any changes in the resident's condition or treatment plan. Despite this, the Medication Administration Records showed that Trazodone was administered multiple times without the representative's knowledge. During interviews, the complainant, who is the resident's Power of Attorney, confirmed they were not consulted about the medication change and expressed concerns about the resident's sensitivity to medications. The Director of Nursing Services acknowledged the lack of notification and documentation regarding the new medication order.
Failure to Follow NPO Order Results in Resident Choking Incident
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice by not adhering to a physician's order for a resident who was designated as nothing by mouth (NPO). The resident, who had a history of cerebral infarction, flaccid hemiparesis, dysarthria, and dysphagia, was admitted with a gastrostomy tube feeding order. Despite the NPO order, the resident was served a breakfast tray and consumed some of the food, which led to a choking incident observed by a family member. Interviews with staff revealed a lack of awareness regarding the resident's NPO status. Nursing assistants acknowledged the presence of a breakfast tray at the resident's bedside, and the Assistant Director of Nursing confirmed the incident, noting that the tray was removed upon discovery. The Director of Nursing indicated that the nursing assistant responsible for the resident was unaware of the NPO order and had obtained the tray from the kitchen, leading to the deficiency in care.
Failure to Provide Adequate Supervision During Meals
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for two residents who required assistance while eating. Resident ID #368, who has a history of dysphagia, Parkinson's disease, and pneumonitis due to aspiration, was observed eating without supervision on multiple occasions. Despite having a physician's order for 1:1 supervision during meals, the resident was left alone, consuming unthickened liquids contrary to the prescribed nectar thick consistency. Staff members, including nursing assistants and registered nurses, were unaware of the supervision requirement, and the resident's care plan did not reflect the need for 1:1 supervision. Resident ID #55, diagnosed with dementia and muscle weakness, also required supervision or assistance with eating. The care plan did not document this need, and the resident was served food that was not cut into bite-sized pieces as ordered. Observations revealed the resident struggling with improperly prepared meals, leading to coughing and difficulty eating. Staff interviews confirmed a lack of awareness regarding the resident's dietary needs and supervision requirements, with the Director of Nursing Services unable to provide evidence of compliance with the physician's diet order. The deficiencies in supervision and adherence to dietary orders for both residents placed them at risk for serious harm. The facility's failure to ensure staff awareness and compliance with physician orders and care plans contributed to these lapses in care. Interviews with various staff members, including nursing assistants, registered nurses, and therapists, highlighted a systemic issue of communication and documentation regarding residents' specific needs during meals.
Failure to Conduct Annual Performance Evaluations for Nursing Assistants
Penalty
Summary
The facility failed to conduct annual performance evaluations for its nursing assistants, as required. A review of personnel files revealed that no performance evaluations had been completed within the last 12 months for five nursing assistants: Staff G, K, L, M, and N. These staff members had been employed since various dates ranging from 2019 to 2022. During an interview with the Director of Nursing Services, it was confirmed that there was no evidence of completed evaluations for these employees within the specified timeframe.
Food Storage and Safety Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and distributed in accordance with professional standards for food service safety. During an initial tour of the kitchen, surveyors observed several items in the walk-in refrigerator that were either past their use-by dates or not labeled and dated, including sour cream containers, a container of vanilla yogurt, Swiss cheese slices, French dressing, a piece of salmon, and white fish fillets. In the walk-in freezer, items such as frozen burgers and cut sausage were found with freezer burn and were not labeled or dated. Additionally, the dry storage area contained a container of honey that was discolored and not dated when opened, as well as frosting spreads that were opened and not dated. In the North unit kitchenette, an opened dairy drink was found without a date. The Food Service Director acknowledged these issues during an interview. Furthermore, the facility did not comply with the Rhode Island Food Code requirement for a 3-bay sink for manually washing, rinsing, and sanitizing equipment and utensils. During a surveyor observation of the main kitchen, there was no evidence of a 3-bay sink being present. The Food Service Director was aware of this requirement and acknowledged that the facility did not have the necessary sink setup. These deficiencies indicate a failure to adhere to established food safety protocols, potentially compromising the safety and quality of food served to residents.
Infection Control Deficiencies in Water Management, Hand Hygiene, and Linen Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies identified during a survey. The facility did not implement a water management program (WMP) based on industry standards or CDC guidelines to prevent Legionella disease. Laboratory results showed Legionella bacteria levels above acceptable limits in certain water stations, but the Maintenance Director was unaware of the need for control measures. Additionally, the facility's water management binder lacked evidence of a water flow assessment to identify areas where Legionella could grow, and there was no documentation of regular flushing of infrequently used fixtures. The facility also failed to implement proper hand hygiene practices for a resident diagnosed with Clostridium difficile (C. diff). Staff members were observed using hand sanitizer instead of washing their hands with soap and water after providing care to the resident, despite the known requirement for soap and water hand hygiene in such cases. The staff involved were either unaware of the resident's C. diff status or did not follow the correct hand hygiene protocol, as confirmed by interviews with the staff and the Director of Nursing Services. Furthermore, the facility did not adhere to appropriate infection control practices regarding the handling and storage of soiled linen. A staff member was observed carrying unbagged, soiled towels from a resident's room and placing them in an overflowing linen bin, which could not be closed. This practice was acknowledged by the staff involved and recognized as an infection control concern by the Director of Nursing Services. The failure to bag soiled linen in the resident's room and the presence of an overflowing linen bin posed a risk of contamination and infection spread within the facility.
Failure to Notify Physician and Follow Medication Orders
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice by not notifying the physician about unavailable medications for two residents and not following a physician's order for medication parameters for another resident. Resident ID #6, admitted with gastro-esophageal reflux disease, had a physician's order for Saccharomyces boulardii to be administered twice daily. However, the medication was unavailable for several days, resulting in 14 missed doses, and there was no evidence that the physician was notified. Similarly, Resident ID #33, readmitted with a urinary tract infection, missed 7 doses of the same medication due to unavailability, and again, the physician was not informed. Additionally, the facility did not adhere to a physician's order for Resident ID #39, who was diagnosed with hypertension. The order specified that metoprolol tartrate should be administered only if the resident's systolic blood pressure was above 110 and heart rate above 55. However, the medication was administered on days when the systolic blood pressure was below the specified threshold, and there was no documentation of the resident's heart rate being checked prior to administration. Staff interviews confirmed these lapses in following the physician's orders and documenting necessary parameters.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and label drugs and biologicals in accordance with accepted professional principles, as observed during a survey. On the Rehab Unit, a Certified Medication Technician (CMT) was found to have pre-poured medications into plastic cups labeled with room numbers, which is against facility policy. Additionally, expired multivitamins and improperly stored Latanoprost eye drops were found on the medication cart. On the North Unit, another CMT was observed pre-pouring medications and labeling them with room numbers. In the medication storage room, a vial of Tuberculin protein derivative was found to be expired, and a bottle of Lorazepam was opened but not dated, despite manufacturer instructions to discard after a certain period. Further observations in the medication storage room on the Rehabilitation unit revealed another vial of Tuberculin protein derivative that was opened and not dated. Interviews with staff confirmed these practices, with acknowledgments that medications were pre-poured, expired medications were not discarded, and opened medications were not dated. The Director of Nursing Services confirmed that pre-pouring medications is not allowed and that medications should be dated when opened and discarded when expired.
Failure to Implement Psychiatric Recommendations for Resident Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The resident, who was admitted in January 2024 with a diagnosis of major depressive disorder, had a care plan dated April 15, 2024, indicating a risk for changes in mood and behavior due to anxiety and depression. A geriatric psychology document from April 6, 2024, recommended Trazodone 12.5 mg as needed for increased anxiety. However, there was no evidence that this recommendation was communicated to or reviewed by a physician. The resident exhibited signs of increased anxiety and depression, as noted in progress notes from April 24, 2024, and May 1, 2024, where the resident refused to shower and be weighed, respectively. On May 3, 2024, a nurse practitioner noted increased anxiety and depression and suggested increasing scheduled Trazodone. Interviews with staff, including a registered nurse and the nurse practitioner, revealed that the recommendation for Trazodone was documented but not acted upon, as there was no evidence of physician notification or order implementation.
Failure to Provide 1:1 Feeding Assistance
Penalty
Summary
The facility failed to ensure that the medical care of a resident, who required 1:1 feeding assistance due to dysphagia and pneumonitis, was properly supervised by a physician. The resident was admitted in June 2024 with a physician's order for 1:1 feeding assistance and aspiration precautions, signed on June 7, 2024. However, during observations on June 11 and June 12, 2024, the resident was seen eating breakfast without staff supervision. The resident's physician admitted to being unaware of the 1:1 supervision requirement, despite having signed the order, as she did not review each order individually before signing. The Director of Nursing Services expressed an expectation that physicians should review orders individually before signing them.
Failure to Provide Appropriate Diets for Residents
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet individual needs for two residents. Resident ID #55, who has severe cognitive impairment and bilateral upper extremity impairments, was observed receiving meals that did not comply with the physician's dietary order for soft, bite-sized foods. On multiple occasions, the resident was served whole and hard food items such as a muffin, sausage link, clam cakes, and bacon, which were not cut into bite-sized pieces and were not soft as required. Staff interviews revealed a lack of awareness and adherence to the resident's dietary needs, with the Director of Nursing Services unable to provide evidence that the resident received the appropriate diet. Resident ID #368, diagnosed with dysphagia and requiring nectar thick liquids and a pureed diet, was observed consuming unthickened coffee and milk, contrary to the physician's order. The resident's dietary needs were clearly documented, yet staff failed to ensure the liquids were thickened as required. Interviews with nursing assistants and the speech therapist confirmed the oversight, and the Director of Nursing Services acknowledged the failure to follow the physician's diet order. These deficiencies highlight a lack of compliance with dietary orders, potentially compromising resident safety.
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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