Heritage Hills Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Smithfield, Rhode Island.
- Location
- 80 Douglas Pike, Smithfield, Rhode Island 02917
- CMS Provider Number
- 415039
- Inspections on file
- 42
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 22 (2 serious)
Citation history
Health deficiencies cited at Heritage Hills Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that two residents receiving chemotherapy via PICC lines did not receive care in accordance with physician orders, facility policy, and professional standards. For one resident, a PICC with a baseline external length of 0 cm had a dressing change documented, but the required external length measurement was left blank; during an observed dressing change, an LPN measured the external length as 1 cm and acknowledged it had not been previously documented. For the second resident, the PICC dressing was not changed on admission and was delayed for nine days, and there was no documentation that the external catheter length was measured as ordered. The NP stated she expected timely dressing changes and external length measurements, and the DON could not provide evidence that these tasks were completed and documented until surveyors raised the concern.
A resident with severe cognitive impairment and a history of Alzheimer’s disease and major depressive disorder was in a day room when another resident with a known history of sexually inappropriate behavior was observed touching the cognitively impaired resident’s lower private area. The incident occurred despite prior documented episodes of inappropriate touching by the same resident toward others, including earlier incidents involving the same victim, and despite a care plan addressing this behavior. Facility records also showed a discrepancy between the documented location of the resident on observation sheets and the actual location where the incident occurred, and leadership could not demonstrate that the involved residents were kept free from abuse.
A resident with dementia and major depressive disorder had physician orders for Seroquel twice daily and at bedtime, along with an order for re-evaluation of these medications. An LPN documented that the re-evaluation with the provider occurred, but later admitted it had not been done, and the orders had been entered for only 14 days. As a result, the Seroquel orders dropped off the MAR and were not re-entered for several days, during which the resident did not receive the prescribed Seroquel doses. The DON later confirmed that the orders had initially been time-limited and had lapsed before being reordered.
A resident with dementia and neuromuscular dysfunction experienced a witnessed fall from bed while one staff member was assisting with turning. Record review showed the resident was dependent for rolling in bed, and the ADL care plan for impaired mobility contained conflicting bed mobility interventions: one entry required two staff and a sheet for turning and repositioning, while a later entry required only one staff and a sheet. The earlier intervention was not removed, leaving the care plan incomplete and unclear about the resident’s actual assistance needs. During interview, the Regional Clinical Director and DON acknowledged the discrepancy and were unable to show that the care plan accurately reflected the resident’s needs.
Two residents at risk for falls did not receive adequate supervision or required safety interventions. One resident with paraplegia fell from bed after being left unattended and without the assistance of two staff as required, while another resident with quadriplegia was found in bed with only one of two ordered floor mats in place. Staff and the DON confirmed that established safety protocols were not followed.
Three residents with pressure ulcers did not receive timely or complete wound care, including missing documentation of wound characteristics and failure to implement or transcribe physician-recommended treatments such as peri-wound skin prep. Orders were not entered into the medical record, resulting in necessary interventions not being provided, as confirmed by staff interviews.
A resident with a history of urine retention was not provided a urology consult as ordered by a physician after a failed trial void. The order was changed to 'as needed' by a nurse, leading to it not being documented for daily follow-up. The resident was later hospitalized with a fever and infection, and the facility administrator acknowledged the failure to schedule the consult.
A resident with Parkinson's disease and moderately impaired cognition missed two medical appointments due to the facility's failure to provide transportation and maintain proper communication. The facility lacked a clear record-keeping system for appointments, leading to missed neurology and dental visits. Staff interviews revealed a lack of awareness and communication regarding the resident's scheduled appointments.
A resident whose primary language is Spanish was given important documents in English, which they could not read, violating their rights. The resident signed financial and admission documents, including a health insurance non-coverage notice, without understanding them. Staff communicated in Portuguese, not Spanish, and the facility failed to provide evidence of documents in the resident's preferred language.
The facility failed to follow physician orders for a resident's urine collection, using a straight catheter without an order, and did not communicate in the resident's native language, causing distress. Another resident's weight was not monitored as ordered, with no evidence of physician notification. The DON could not provide evidence of compliance.
The facility failed to maintain an effective infection prevention and control program, with deficiencies in scabies management, Enhanced Barrier Precautions (EBP), and wound care practices. Staff did not follow protocols for bagging and removing belongings of residents with suspected scabies, and failed to wear appropriate PPE during high-contact care activities. Additionally, the laundry room lacked gowns for handling soiled linens, indicating significant lapses in infection control measures.
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of antibiotic review processes and monitoring for two residents prescribed antibiotics. The Infection Preventionist, new to the role, had not been trained to conduct antibiotic timeouts, and the Regional Nurse acknowledged the need for improvement in this area.
The facility failed to manage a Freestyle Libre sensor for a diabetic resident, lacking documentation and physician orders. Additionally, daily weights and wound care orders for another resident were not consistently followed, and wound care documentation for two residents was incomplete. Staff interviews confirmed these deficiencies.
The facility failed to ensure residents received necessary specialist appointments, impacting three residents with conditions requiring follow-up care. One resident with a traumatic brain injury did not have a neurology appointment scheduled, another with mouth pain did not see a dentist, and a third with a diabetic foot infection did not have a podiatrist appointment. Staff interviews confirmed these oversights.
The facility failed to provide adequate pressure ulcer care for two residents. One resident had no physician's order for an ankle wound, and staff were unsure how to prepare the correct Dakin's solution. Another resident's wound care did not match updated recommendations, and a float nurse was unaware of the treatments. The DON could not provide evidence of proper care, indicating a failure to meet professional standards.
The facility failed to provide sufficient nursing staff, resulting in delayed responses to call lights and inadequate care for residents. A resident was observed self-toileting due to lack of assistance, while another remained soiled before a wound dressing change. Staff shortages were reported, with fewer nursing assistants than required, leading to delays in morning care. The Director of Nursing Services could not justify the staffing inadequacies.
The facility failed to ensure nursing staff had the necessary competencies for wound care and hypodermoclysis. An LPN provided wound care without a physician's order and used unclean equipment, while another LPN did not clean scissors before use. An RN did not assess the drip rate for hypodermoclysis, leading to incorrect infusion rates. Competency assessments were incomplete or missing, and staff interviews revealed a lack of proper training.
The facility failed to address pharmacy recommendations for three residents, leading to deficiencies in medication management. A resident's medication orders lacked diagnoses, another's liquid concentrate orders were not updated with both milligrams and milliliters, and a third resident's anticoagulant monitoring and scheduling were not adjusted as recommended. The DNS and Regional Nurse acknowledged these issues.
The facility experienced a medication error rate of 56%, involving several residents. Errors included late administration of medications, incorrect administration of Tums, improper infusion rate of D5 solution, and failure to check apical pulse before administering Metoprolol Tartrate. Additionally, Prevacid was crushed against instructions. Staff acknowledged these errors, and the facility could not demonstrate adherence to its medication administration policy.
A resident with moderate cognitive impairment and medical conditions requested an external catheter at night for comfort, which was agreed upon by a nurse practitioner. However, the catheter was not consistently provided, as evidenced by treatment records and staff interviews. The facility failed to adhere to the resident's care plan, impacting their wellbeing.
A resident on hospice care was found with an empty oxygen tank, and staff were unable to promptly replace it due to a lack of knowledge about oxygen supply locations and prioritization of other tasks. The resident's oxygen level dropped significantly before the DNS intervened to replace the tank.
A resident with severe cognitive impairment and multiple pressure ulcers experienced inadequate pain management during wound care. Despite repeated complaints of pain, the LPN continued treatment without notifying a provider or using non-pharmacological interventions. The resident had only received Tylenol earlier in the day, and the Director of Nursing could not provide evidence of effective pain management.
A facility failed to maintain accurate medical records for a resident with vascular wounds. The resident, admitted with type II diabetes mellitus and heart failure, had a physician's order for an Unna Boot treatment, which was later changed to clobetasol and a tubi grip. Despite this change, the treatment records inaccurately documented the completion of the Unna Boot treatment. Observations confirmed the absence of the Unna Boot, and staff interviews revealed a lack of explanation for the inaccurate documentation.
A facility failed to follow physician's orders for daily wound dressing changes for a resident with hemiplegia, hemiparesis, and type 2 diabetes. The resident's dressing was not changed as ordered, and staff interviews confirmed the oversight. The Regional Director expected compliance with the orders, but an LPN admitted to inaccurately documenting the dressing change.
A resident with hemiplegia and hemiparesis fell in the shower while unsupervised by a licensed NA, resulting in bruises and a scratch. The resident required substantial assistance for showers, but was left alone with a nursing student when the NA stepped out. The facility failed to provide evidence of adequate supervision, as required by their agreement with the nursing school.
A resident with COVID-19 was not properly isolated due to staff failing to wear required PPE. Despite signage indicating necessary precautions, a Nursing Assistant and a Physical Therapy Assistant entered the room without full PPE, including missing gowns and eye protection. Both staff members acknowledged their oversight, and the facility's leadership confirmed the breach in infection control protocols.
A resident with a UTI and DVT did not receive medications as ordered, with several medications administered late and one not given at all. The DON acknowledged the failure to follow physician's orders, which included specific times for medication administration.
A facility failed to securely store tramadol, a Schedule IV controlled substance, leading to 22 missing pills for a resident with dementia and pain. The medication was not logged or stored properly, resulting in a breach of professional principles for medication security.
A resident with cognitive impairments and identified as an elopement risk was transported to a medical appointment unaccompanied by facility staff, leading to the resident's successful elopement. The resident's wander bracelet was removed, and the resident's whereabouts became unknown after the appointment was canceled. The resident was found by facility staff on a main road approximately 8 miles from the facility. The facility failed to implement its policy on wandering and elopement, resulting in inadequate supervision and significant risk to the resident's safety.
A medication administration error occurred when a nurse in training, under inadequate supervision, administered the wrong medications to a resident. The preceptor prepared the medications and handed them off to the trainee, who misheard the room number and administered them to the wrong resident. The facility's policy on medication administration was not followed, and the trainee's competency had not been demonstrated.
A resident with multiple health conditions was administered incorrect medications by a nurse in training, leading to dizziness and a significant drop in blood pressure. The error was identified promptly, and the resident was monitored closely, but the facility failed to ensure adherence to its medication administration policy.
Failure to Follow PICC Line Dressing and Measurement Orders for Two Chemotherapy Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide PICC line care and dressing changes according to physician orders, facility policy, and professional standards of practice for two residents receiving chemotherapy via PICC lines. For Resident ID #1, hospital documentation showed a PICC was inserted in the left arm with a baseline external catheter length of 0 cm, and the resident was to receive chemotherapy through this line. The January 2026 MAR contained a physician’s order to change the central line dressing every 7 days and to measure the external catheter length with each dressing change. The dressing change was signed as completed on 1/31/2026, but the documentation field for the catheter length was left blank. During a surveyor-observed dressing change on 2/6/2026, an LPN measured the external catheter length as 1 cm and acknowledged that the external length had not been documented previously in the resident’s record. For Resident ID #2, hospital records indicated a PICC was inserted in the right arm with a baseline external catheter length of 0 cm, and this resident was also to receive chemotherapy via the PICC. The January 2026 MAR showed a physician’s order to change the central line dressing every 7 days and to measure the external catheter length, but the order was marked incomplete due to the resident being absent from the facility. The PICC dressing was not changed on admission and was not completed until 2/6/2026, nine days later, and there was no evidence in the record that the external catheter length was measured as required by facility policy and the physician’s order. During interviews, the Nurse Practitioner stated she expected PICC dressings to be changed as ordered and the external length measured and reported if different from baseline, and the Director of Nursing Services was unable to provide evidence that the PICC dressing and external length measurements had been completed and documented for either resident until the surveyor brought the issue to the facility’s attention.
Failure to Prevent Repeated Sexual Abuse Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse when another resident with a known history of sexually inappropriate behavior inappropriately touched the resident’s lower private area in a unit day room. On the date of the incident, an Activities Aide walking by the South Unit day room observed one resident in a wheelchair positioned beside another resident’s chair and touching the other resident’s lower private area. The staff member immediately intervened, separated the residents, and notified the nurse. Both residents were assessed and found without injuries. The resident who was touched had been admitted with diagnoses including Alzheimer’s disease and major depressive disorder, and a recent MDS assessment documented severe cognitive impairment. Record review showed that the resident who engaged in the touching had an existing care plan, initiated months earlier, addressing a history of sexually inappropriate behavior and inappropriate touching of other residents and staff. The care plan documented multiple prior incidents of inappropriate touching involving other residents, including two earlier incidents with the same cognitively impaired resident. Despite these prior events and care plan focus, the resident continued to engage in inappropriate touching. Documentation also showed a discrepancy between the location recorded on a 15‑minute observation sheet, which indicated the resident was at the nurse’s station on a different unit at the time of the incident, and the actual location of the incident in the South Unit day room. During interview, the Administrator acknowledged the prior inappropriate touching incidents involving these residents and the implementation of interventions but could not provide evidence that the affected residents were kept free from abuse by the resident with sexually inappropriate behavior.
Failure to Follow Physician Orders for Seroquel Resulting in Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services met professional standards of quality by not properly following physician orders for Seroquel for one resident. The resident was admitted with dementia with behavioral disturbances and major depressive disorder and had physician orders for Seroquel 50 mg by mouth twice daily starting 12/20/2025 and Seroquel 25 mg by mouth at bedtime starting 12/19/2025. There was also a physician order to re-evaluate the Seroquel orders with the provider on 1/2/2026. The January 2026 MAR showed that this re-evaluation order was signed off as completed by an LPN, indicating the medications were re-evaluated with the provider, but progress notes contained no evidence that such a re-evaluation occurred. During an interview, the LPN stated she had signed that she re-evaluated the Seroquel order with the provider but acknowledged that she had not done so. She also revealed that when the Seroquel orders were initially entered, they were entered for only 14 days. The January 2026 MAR showed that the last administration of the twice-daily Seroquel was on 1/2/2026 at 1:00 PM and the last administration of the bedtime Seroquel was on 1/1/2026, after which both orders were no longer in place. The same Seroquel orders were not re-entered until 1/10/2026 and 1/11/2026, resulting in the resident not receiving Seroquel as ordered for a total of 8 days. The DON acknowledged that the Seroquel orders had initially been entered for only 14 days and that, upon later review, the orders were found to be no longer in place.
Inaccurate Care Plan Documentation for Bed Mobility Assistance
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurately documented medical records for a resident with dementia and neuromuscular dysfunction who was admitted in April 2023. A community complaint reported to the state health department raised concerns about safety and care practices surrounding the resident’s fall on 1/12/2026. Nursing progress notes documented that the resident experienced a witnessed fall in his/her room while care was being provided, when one staff member was assisting with turning in bed and the resident fell out of bed onto the floor. A Quarterly MDS assessment indicated the resident was dependent for rolling in bed from back to side and returning to back. Review of the resident’s ADL care plan, initiated 4/14/2023 for physical limitations related to impaired mobility, showed conflicting interventions for bed mobility. One intervention, dated 6/7/2024, stated the resident required the assist of two staff and a sheet for turning and repositioning, while a later intervention, dated 12/23/2025, stated the resident required the assist of one staff and a sheet for turning and repositioning. The care plan did not clearly indicate which level of assistance was current, resulting in an incomplete and inaccurate description of the resident’s needs for turning and repositioning in bed. During an interview, the Regional Clinical Director, with the DON present, acknowledged that the earlier two-person assist intervention should have been removed when the one-person assist intervention was implemented and could not provide evidence that the care plan accurately reflected the resident’s needs.
Failure to Provide Adequate Supervision and Accident Prevention for Residents at Risk for Falls
Penalty
Summary
The facility failed to provide adequate supervision and care to prevent accidents for two residents identified as being at risk for falls. One resident with paraplegia, who was cognitively intact and dependent on two staff members for bed mobility, was left unattended at the bedside during care. The nursing assistant elevated the bed to waist height and did not return it to the lowest position. While the resident was positioned on their side for wound treatment, the staff member stepped away to call for a nurse, during which time the resident fell from the bed and required hospital evaluation and admission. Documentation indicated that the resident required two staff for repositioning and use of a turning sheet, but this protocol was not followed at the time of the incident. Another resident with spastic quadriplegia, who had a physician's order and care plan interventions for the bed to be kept in a low position with floor mats on both sides, was observed to have only one floor mat in place while in bed. Staff confirmed that a floor mat was missing from one side and acknowledged that both should have been present according to the care plan and physician's order. The DON was unable to provide evidence that the required safety interventions were in place for this resident at the time of observation.
Failure to Provide Timely and Complete Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for residents with pressure ulcers, as required by professional standards of practice. Three residents with existing pressure injuries did not receive timely or complete wound care interventions. For one resident admitted with a coccyx pressure injury, there was no documentation of the wound's stage, description, or characteristics upon admission, and no treatment order was implemented for two days. Recommendations from the wound physician, including the application of skin prep to the peri-wound area, were not transcribed into the medical record, resulting in the treatment not being administered. Another resident admitted with multiple wounds, including stage III pressure injuries to both heels, also did not receive recommended peri-wound skin prep. Although the wound physician made specific recommendations during wound rounds, these were not transcribed into the medical record, and there was no evidence that the treatments were provided. The care plan for this resident included administering treatments as ordered, but the necessary interventions were not carried out. A third resident with a stage IV pressure ulcer of the right lateral ankle and a wound to the right knee similarly did not receive the recommended skin prep treatment. The wound nurse communicated the physician's recommendations to the provider, who approved them, but failed to transcribe the orders, resulting in the treatments not being given. Interviews with staff confirmed that the recommended treatments were not implemented for all three residents, and there was no documentation to show that the required wound care was provided.
Failure to Schedule Urology Consult as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not following a physician's order for a urology consult. The resident, admitted in November 2024 with a diagnosis including retention of urine, had a physician's order dated 12/9/2024 to obtain a urologist consult if a trial void failed every shift. This order was later changed by a nurse to an 'as needed' order on 12/21/2024, which resulted in the order not appearing on the Treatment Administration Record for daily sign-off by staff. The resident experienced a failed trial void on 12/10/2024, as documented in the progress notes, and a urology consult was ordered by the nurse practitioner. However, the facility did not schedule the urology consult as required. The resident was later taken to the hospital with a fever and infection, where it was discovered that the catheter was extremely dirty, likely causing a urinary tract infection. The administrator acknowledged during a surveyor interview that the urology consult appointment was not scheduled, confirming the facility's failure to adhere to the physician's order.
Resident Misses Multiple Medical Appointments Due to Facility Oversight
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, as evidenced by the resident missing two out of three scheduled medical appointments. The resident, who was admitted with a diagnosis of Parkinson's disease and had moderately impaired cognition, missed a neurology appointment on January 7, 2025, and two dental appointments on November 21, 2024, and December 16, 2024. The facility did not provide transportation for the neurology appointment, and there was no communication from the facility regarding the missed appointment. Additionally, there was no evidence of follow-up documentation or continuity of care documents in the resident's medical record for these appointments. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's scheduled appointments. A registered nurse recalled a family member inquiring about an upcoming appointment but could not provide details about the conversation. The Assistant Director of Nursing Services indicated that multiple staff members were responsible for scheduling appointments, but there was no clear record-keeping system for past appointments. The Regional Director of Clinical Services and the ADNS acknowledged the absence of continuity of care documents and confirmed that the resident did not attend the scheduled neurology or dental appointments.
Failure to Provide Documents in Resident's Preferred Language
Penalty
Summary
The facility failed to ensure that a resident received important documents in a language they understand, which is a violation of their rights. The resident, whose primary language is Spanish, was given financial and admission documents in English, which they could not read. This included a notice of health insurance non-coverage and an admission packet, both of which were signed by the resident despite not being in their preferred language. The resident's Quarterly Minimum Data Set (MDS) assessment confirmed that their preferred language is not English. Interviews conducted during the survey revealed further issues. The resident's representative, who translated for the resident, reported that a staff member instructed the resident to sign the documents or face the possibility of having to leave the facility. Additionally, the staff member communicated in Portuguese, not Spanish, further complicating the resident's understanding. The Admissions Coordinator and the Administrator both acknowledged that the documents were not provided in Spanish, and the Administrator could not provide evidence that the documents were available in the resident's preferred language.
Failure to Follow Physician Orders for Urine Collection and Weight Monitoring
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. For one resident, a urine sample was collected via a straight catheter without a physician's order, despite the resident being able to provide a sample through urination. The resident, who does not speak English, was not adequately informed about the procedure in their native language, Spanish, leading to distress and fear during the process. The nurse involved could not provide evidence of an order for the catheterization, and the nurse practitioner confirmed that no such order was given. The physician also indicated that a clean urine catch is the standard method unless otherwise specified in an order. Another resident experienced a significant weight loss, and the facility failed to obtain the resident's weight as ordered by the physician. The resident's weight was supposed to be recorded weekly for four weeks and then monthly, but records showed that the weights were not obtained on the specified dates. Additionally, there was no evidence that the physician or provider was notified about the missed weight recordings. The Director of Nursing Services was unable to provide evidence that the weights were obtained or that the physician was informed of the oversight.
Infection Control Deficiencies in Scabies Management and PPE Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the survey. Two residents with suspected scabies did not have their belongings bagged and removed from their rooms as per the facility's policy and physician's orders. Despite being informed of the potential scabies cases, staff did not follow the required procedures, and the Director of Housekeeping did not ensure the removal and storage of the contaminated items. This lack of adherence to protocol was confirmed through staff interviews and observations, where no black bags were found in the designated storage area. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for residents requiring such measures. Staff failed to wear the appropriate personal protective equipment (PPE) during high-contact care activities, such as administering medication through a feeding tube and providing wound care. Observations revealed that staff did not don gowns as required, and in one case, a resident was not even placed on EBP until after the surveyor's intervention. This oversight was acknowledged by the staff and the Director of Nursing Services, indicating a gap in the facility's infection control practices. The facility also demonstrated deficiencies in wound care practices. Staff did not adhere to the no-touch technique, as evidenced by the use of unclean scissors and improper glove use during wound dressing changes. Furthermore, the laundry room lacked gowns for handling soiled linens, and staff admitted to not wearing gowns while sorting contaminated laundry. These observations highlight significant lapses in the facility's infection control measures, as staff failed to follow established protocols and policies, potentially compromising resident safety.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an effective Infection Prevention and Control Program (IPCP) that includes an antibiotic stewardship program with protocols and a system to monitor antibiotic use. This deficiency was identified for two residents, both of whom were prescribed antibiotics without evidence of an antibiotic review process or formal tracking and monitoring of their antibiotic use. Resident ID #78 was readmitted with diagnoses including dementia and type II diabetes mellitus and was prescribed Keflex for a foot infection. However, there was no evidence of an antibiotic timeout to assess the continued need for the antibiotic. Similarly, Resident ID #194, readmitted with type II diabetes mellitus, was prescribed Augmentin for a bacterial infection, but again, there was no evidence of an antibiotic review process. During interviews, the Infection Preventionist (IP), who had recently assumed the role, admitted to not completing antibiotic timeouts or maintaining line listings of residents on antibiotics due to a lack of training. The Regional Nurse confirmed that the facility should conduct antibiotic timeout assessments and acknowledged that the facility could improve in this area. The facility was unable to provide evidence of a system to monitor antibiotic use, which is necessary to ensure residents are prescribed the appropriate antibiotics.
Deficiencies in Sensor Management, Weight Monitoring, and Wound Care Documentation
Penalty
Summary
The facility failed to meet professional standards of quality in the management of a Freestyle Libre sensor for a resident with diabetes. The resident, who was admitted with diagnoses including diabetes and acute kidney failure, had a Freestyle Libre sensor that was not documented in the medical records, and there was no physician's order for its use or replacement. Interviews with staff, including an LPN and the Director of Nursing Services (DNS), confirmed the lack of documentation and orders, despite the sensor being used to monitor the resident's blood glucose levels. The facility also failed to adhere to physician's orders for daily weights and wound care for another resident with a prosthetic heart valve and heart failure. The resident's hospital discharge summary included an order for daily weights, which was not consistently followed, resulting in missed opportunities to monitor the resident's weight changes. Additionally, the facility did not perform daily dressing changes on surgical wounds as ordered, with evidence showing that dressings were not changed on the specified dates. Furthermore, the facility did not document wound care assessments for residents with non-pressure wounds according to policy and standard practice. One resident with a vascular wound lacked documentation of wound characteristics from June to September, and the facility could not provide wound care notes from an outside provider. Another resident with a diabetic foot infection had incomplete documentation of wound characteristics upon admission, and there was no initial wound evaluation recorded. Interviews with staff, including a float nurse and the DNS, revealed gaps in wound care documentation and evaluation.
Failure to Schedule Specialist Appointments for Residents
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and their comprehensive care plans. This deficiency was identified for three residents who required specialist appointments. One resident, admitted with traumatic brain injury and subarachnoid hemorrhage, was prescribed Keppra for seizure activity and required a follow-up appointment with neurology. However, there was no evidence of the appointment being made until it was brought to the facility's attention by a surveyor. Another resident, admitted with skin cancer and hypertension, complained of mouth pain and was prescribed Tylenol with a follow-up appointment with a dentist. The facility failed to make the dental appointment. Additionally, a third resident, admitted with type II diabetes mellitus and orthopedic aftercare following surgical amputation, required a follow-up with a podiatrist for a diabetic foot infection. The facility did not make this appointment either. Interviews with staff, including an RN, LPNs, and the Director of Nursing Services, confirmed the lack of appointments for these residents.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for residents with pressure ulcers, as observed in two cases. Resident ID #5 was admitted with pressure ulcers and a care plan indicating the need for wound care. However, there was no physician's order for treating the right ankle wound, and the LPN was observed using an incorrect concentration of Dakin's solution due to a lack of knowledge on how to prepare the correct dilution. The wound physician and other staff members were also unsure about the correct preparation of the solution, and there was no order in place for the ankle wound treatment. Resident ID #62 was admitted with pressure ulcers and was under the care of an in-house wound physician. Despite recommendations to discontinue certain treatments, the physician's orders still included them, leading to a mismatch between the wound care provided and the recommendations. A float nurse was unaware of the resident's wound treatments and did not perform them, indicating a lack of communication and adherence to updated wound care protocols. The Director of Nursing Services was unable to provide evidence that both residents received appropriate pressure ulcer care to promote healing and prevent infection. The discrepancies in treatment orders and the lack of proper wound care highlight the facility's failure to ensure that residents with pressure ulcers receive care consistent with professional standards of practice.
Insufficient Nursing Staff Leads to Delayed Care and Resident Neglect
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the needs of residents, impacting their safety and well-being. During the survey, it was observed that the facility did not utilize contracted nursing staff despite staffing challenges. Residents reported long wait times for staff response to call lights, particularly during the night and evening shifts. Specific instances included a resident on the East Unit experiencing delays during the 11:00 PM to 7:00 AM shift, and another resident on the South Unit not receiving assistance to get out of bed until the afternoon. Nursing assistants reported being short-staffed, with fewer staff members than required, leading to delays in providing morning care. One resident, admitted with difficulty in walking, was observed self-toileting due to a lack of staff assistance, despite having triggered the call light. Staff members were seen walking by without providing help, and the call light was turned off without assistance being rendered. The Regional Nurse expected staff to respond to call lights within 2 to 5 minutes, which was not adhered to in this case. Another resident, admitted with pressure ulcers and urinary incontinence, was found saturated in urine prior to a scheduled wound dressing change. The staff member conducting the wound care did not provide incontinence care beforehand, and the resident remained soiled for over 30 minutes. The nursing assistant responsible for the resident was unsure when the last incontinence care was provided. The Director of Nursing Services could not explain the lack of care or provide evidence of sufficient staffing to ensure resident safety and well-being.
Deficiencies in Nursing Competencies and Procedures
Penalty
Summary
The facility was found to have deficiencies in ensuring that nursing staff possessed the appropriate competencies and skills to provide safe and effective care to residents. Specifically, the facility failed to ensure that staff followed proper procedures for wound care and hypodermoclysis. In one instance, a Licensed Practical Nurse (LPN), identified as Staff E, provided wound care to a resident's ankle without a physician's order and used an unclean wash basin to mix wound care solution. This was despite the facility's policy requiring a physician's order for wound care procedures and the competency assessment for Staff E, which emphasized the need for such an order and proper preparation techniques. Another deficiency was observed with a different LPN, identified as Staff A, who failed to clean scissors before using them to cut a sterile wound dressing for a resident. The competency assessment for Staff A was incomplete, missing pages and signatures, indicating a lack of proper training verification. Additionally, the facility's policy on hypodermoclysis was not adhered to by Registered Nurse (RN) Staff B, who did not assess the drip rate of a hypodermoclysis infusion as required. The RN set up the infusion but failed to ensure the correct flow rate, resulting in the solution infusing at a slower rate than ordered. The facility's failure to provide adequate training and competency assessments for its nursing staff was further highlighted by the lack of evidence that staff were competent in performing hypodermoclysis and wound care. Interviews with staff and the Regional Nurse revealed that staff were not calculating drip rates for hypodermoclysis and were performing wound dressings without physician orders. The Director of Nursing Services and the Regional Nurse could not provide evidence of staff competencies, underscoring the facility's deficiency in maintaining the highest practicable well-being of its residents.
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to address pharmacy recommendations in a timely manner for three residents, leading to deficiencies in medication management. For Resident ID #15, the facility did not complete the diagnoses for use on medication orders lacking reasons, despite repeated recommendations from the consultant pharmacist in June, July, and August 2024. The medications involved included Divalproex Sodium, Risperidone, Atorvastatin, Flomax, Levothyroxine, Vitamin B1, and Trazodone. The Director of Nursing Services acknowledged that these recommendations had not been addressed. For Resident ID #58, the facility did not update liquid concentrate orders to include both milligrams and milliliters, as recommended by the pharmacist in July and August 2024. This omission involved medications such as Lorazepam Intensol and Morphine Sulfate Concentrate. Additionally, for Resident ID #63, the facility failed to document regular monitoring for signs of bleeding for a resident on Eliquis and did not adjust the medication schedule to every 12 hours as recommended. The Director of Nursing Services and the Regional Nurse acknowledged these deficiencies during a surveyor interview.
Medication Administration Errors Exceeding 5% Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 56% based on 25 observed opportunities for error. This deficiency involved multiple residents and was identified through surveyor observations, record reviews, and staff interviews. For Resident ID #241, medications were administered 3 to 4 hours late, and the LPN acknowledged the frequent lateness of medication administration. Resident ID #83 also received medications 3 to 4 hours late, and Tums were administered incorrectly after meals instead of before. Resident ID #191's D5 solution infusion was set at an incorrect drip rate, and the RN failed to assess the drip rate as required. Additionally, Resident ID #74's Metoprolol Tartrate was administered without checking the apical pulse, and Prevacid was crushed contrary to instructions. Staff interviews confirmed these errors, and the Regional Nurse, along with the Director of Nursing Services, could not provide evidence that the facility ensured a medication error rate below 5%. The facility's policy on administering medications emphasizes timely and accurate administration, which was not adhered to in these instances.
Failure to Provide Ordered External Catheter
Penalty
Summary
The facility failed to provide services to attain and maintain the highest practicable physical, mental, and psychosocial wellbeing for a resident who was reviewed for the use of an external catheter. The resident, who was admitted with diagnoses including type II diabetes mellitus and heart failure, had a moderate cognitive impairment. A progress note indicated that the resident requested an external catheter at night to improve quality of life, and the nurse practitioner agreed to this request. However, the resident reported to the surveyor that the external catheter was only provided on one occasion and not consistently thereafter, despite the order being in place. The September 2024 Treatment Administration Record showed that the external catheter was not used for 5 out of 10 opportunities. During interviews, a Licensed Practical Nurse confirmed the catheter was not signed off as in use for these opportunities and could not explain the discrepancy. The Director of Nursing Services stated that if the resident refused the catheter, there should be a progress note, but no such evidence was provided. This indicates a failure to adhere to the resident's care plan and preferences, impacting their wellbeing.
Failure to Provide Timely Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident who was on oxygen therapy. The resident, who had been admitted to hospice care, was observed by a surveyor to have an empty oxygen tank. Despite the presence of staff, including a Certified Medication Technician (CMT) and a Licensed Practical Nurse (LPN), there was a delay in addressing the empty oxygen tank. The CMT was unable to locate a replacement tank and the LPN prioritized other tasks over the resident's immediate need for oxygen. The situation was further complicated by the lack of knowledge among staff about the location of oxygen supplies and the absence of oxygen concentrators in the facility. The Director of Nursing Services (DNS) eventually intervened to replace the oxygen tank, but by that time, the resident's oxygen level had dropped to 78%, which is below the normal range. The report highlights the facility's failure to ensure that oxygen therapy was administered promptly and effectively, as required by professional standards.
Inadequate Pain Management During Wound Care
Penalty
Summary
The facility failed to provide adequate pain management for a resident with severe cognitive impairment and multiple pressure ulcers. The resident, admitted in August 2023, had a history of pressure ulcers and was noted to have a severely impaired cognition score. The care plan indicated the need for monitoring and treating pain, as well as assessing and anticipating the resident's needs for comfort and body positioning. However, during a surveyor observation, the resident was found to be in significant pain during wound care, yelling and attempting to retract their leg, without receiving appropriate pain management. The Licensed Practical Nurse (LPN) administering the wound care confirmed that the resident had only received Tylenol at 6:00 AM and had no other pain medication available. Despite the resident's repeated complaints of pain, the LPN continued the treatment without notifying a provider or using non-pharmacological interventions as outlined in the care plan. The Director of Nursing Services was unable to provide evidence that the resident was kept free from pain, highlighting a deficiency in the facility's pain management practices.
Inaccurate Medical Record Documentation for Resident with Vascular Wounds
Penalty
Summary
The facility failed to maintain accurate medical records for a resident with vascular wounds, as determined by surveyor observation, record review, and staff interviews. The resident, who was admitted in June 2024 with diagnoses including type II diabetes mellitus and heart failure, had a physician's order for an Unna Boot treatment to be applied twice weekly. However, a progress note from August 2024 indicated that the treatment was changed to clobetasol and a tubi grip following a wound clinic visit. Despite this change, the September 2024 Treatment Administration Record inaccurately documented that the Unna Boot treatment was completed on specific dates. Surveyor observations in mid-September 2024 confirmed that the resident did not have an Unna Boot in place, contradicting the treatment records. Interviews with a registered nurse and the Director of Nursing Services revealed that the Unna Boot order should have been discontinued, and they were unable to explain why the treatment was still being signed off as completed. This discrepancy highlights a failure in maintaining accurate medical records in accordance with professional standards and practices.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice and did not follow physician's orders for daily wound dressing changes for a resident. The resident, who was admitted with conditions including hemiplegia, hemiparesis, and type 2 diabetes, had a physician's order for a daily dressing change on a wound on the right arm. However, the treatment administration record showed that the dressing was last changed as ordered on August 14, 2024, by an LPN. During a surveyor interview, the resident could not recall if the dressing had been changed, and an observation revealed that the dressing was last labeled on August 13, 2024. Interviews with staff confirmed the deficiency. An LPN acknowledged that the dressing was not changed as ordered on August 14, 2024, and the Regional Director of Clinical Services stated that she expected the dressing to be changed per the physician's orders. Another LPN admitted to documenting the dressing change as completed on August 14, 2024, despite not having performed the task. This failure to adhere to the physician's orders and maintain accurate records led to the deficiency identified by the surveyors.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident who was at high risk for falls. The resident, who had a history of hemiplegia and hemiparesis following a stroke, required substantial assistance for showers. On the day of the incident, a nursing assistant (NA) was working with a nursing student to provide care to the resident. The NA left the resident alone with the nursing student in the shower room to retrieve an item from the linen cart. During this time, the resident fell out of the shower chair, resulting in bruises to the right buttock and posterior thigh, as well as a scratch on the right ankle. The incident was reported to the Rhode Island Department of Health, and a subsequent investigation revealed that the nursing student was unsupervised by a licensed NA at the time of the fall. The facility's agreement with the Rhode Island College School of Nursing indicated that the facility was responsible for client care and the supervision of nursing students. However, the facility was unable to provide evidence that the resident was kept free from accidents, highlighting a lapse in supervision and adherence to the care plan designed to mitigate the resident's fall risk.
Inadequate Infection Control Practices for COVID-19 Positive Resident
Penalty
Summary
The facility failed to maintain appropriate infection control practices for a resident who was on isolation precautions due to a positive COVID-19 diagnosis. The resident, who was admitted in July 2024, had diagnoses including urinary tract infection, septicemia, and dementia. During a surveyor observation, it was noted that the resident's room had signage indicating it was an isolation room, requiring staff and visitors to wear specific personal protective equipment (PPE) such as a gown, N95 mask, eye protection, and gloves before entering. However, the surveyor observed that Nursing Assistant (NA), Staff E, was in the resident's room without the required PPE, specifically missing a gown and eye protection. Physical Therapy Assistant, Staff F, was also present in the room without wearing the necessary eye protection. Both staff members acknowledged their failure to adhere to the required infection control practices. The Assistant Director of Nursing Services and the Regional Director of Clinical Services confirmed that the staff did not follow the expected infection control protocols.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not following physician's orders. A complaint was submitted to the Rhode Island Department of Health alleging that a resident did not receive some medications and others were administered late. The resident, who was admitted in July 2024 with diagnoses including urinary tract infection (UTI) and deep vein thrombosis (DVT), had specific physician's orders for medications to be administered at designated times. On July 26, 2024, the Medication Administration Record (MAR) showed that several medications, including Ferrous Sulfate, Eliquis, Mucinex, Clopidogrel Bisulfate, Aspirin, Atorvastatin Calcium, Metoprolol Tartrate, Mometasone Furoate inhaler, Anoro Ellipta inhaler, and Bumex, were administered at 12:30 PM instead of the ordered time of 9:00 AM. Additionally, Cephalexin, ordered for administration every six hours, was not given at 12:00 AM as required. The Director of Nursing Service acknowledged during an interview that the Cephalexin was not administered as ordered and that the 9:00 AM medications were given late.
Failure to Securely Store Controlled Substances
Penalty
Summary
The facility failed to store medications in accordance with accepted professional principles, specifically regarding the secure storage of controlled substances. This deficiency was identified during a review of records and staff interviews, which revealed that 22 pills of tramadol, a Schedule IV controlled substance, were missing for a resident with dementia, anxiety disorder, and right hip pain. The resident had a physician's order for tramadol 25 mg to be administered twice daily for pain. The facility's policy required controlled substances to be counted upon delivery and documented in a narcotic log book, but this procedure was not followed. Staff interviews indicated that the tramadol was delivered to the facility and signed for by an LPN, who then allegedly handed it over to an RN. However, the RN denied receiving the medication, and the subsequent shift LPN was unaware of the delivery, as the medication was not logged. The missing tramadol was later found mixed with non-narcotic medications in a medication cart, indicating a failure to limit access and maintain secure storage, as required for controlled substances.
Failure to Provide Adequate Supervision for Elopement Risk Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as an elopement risk, received adequate supervision, leading to the resident successfully eloping from the facility. The resident, who had diagnoses including mild cognitive impairment and schizoaffective disorder, was admitted with a care plan indicating a risk for elopement. Despite this, the resident was transported to a medical appointment unaccompanied by facility staff, and the wander bracelet was removed prior to the appointment. The resident's whereabouts became unknown after the appointment was canceled, and the resident took several buses to multiple locations before being found by facility staff on a main road approximately 8 miles from the facility. This incident occurred despite previous elopement attempts and recommendations for close supervision due to cognitive impairments and functional decline. The facility's policy on wandering and elopement was not effectively implemented, and there was no evidence of a policy for escorting residents to medical appointments. Interviews with staff and the resident confirmed that the resident was left unsupervised, and the Assistant Director of Nursing admitted to removing the wander bracelet to prevent loss in case of hospital admission. The Medical Director was unaware of the resident's unsupervised appointment and subsequent elopement. The facility's failure to provide adequate supervision resulted in the resident being unsupervised in the community, posing a significant risk to the resident's safety.
Medication Administration Error Due to Inadequate Supervision and Competency
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to provide safe and effective care, as evidenced by a medication administration error involving a resident. The incident occurred when a nurse in training, under the supervision of a preceptor, administered the wrong medications to a resident. The preceptor prepared the medications and handed them off to the trainee, who then misheard the room number and administered the medications to the wrong resident. This error was later realized when the preceptor attempted to give the correct medications to the resident, only to find out that the trainee had already administered the wrong ones. The resident involved in the incident had been readmitted to the facility with multiple diagnoses, including hypertension, acute kidney failure, acute pyelonephritis, and chronic obstructive pulmonary disease. The medications administered in error included Aspirin, Duloxetine, Linezolid, Oxycontin ER, Flomax, and Metoprolol Succinate ER. The facility's policy on medication administration, which requires verification of the resident's identity and adherence to the 'five rights' of medication administration, was not followed. The preceptor's decision to allow the trainee to administer medications unsupervised contributed to the error. Interviews with facility staff, including the Unit Supervisor and the Director of Nursing Services (DNS), confirmed that the preceptor should have been present with the trainee during medication administration. The DNS acknowledged that the preceptor should not have been pouring medications for the trainee to administer and that the nurse who prepares the medication should be the one to administer it. Additionally, there was no evidence that the trainee had demonstrated competency in medication administration at the time of the error.
Significant Medication Error Due to Nurse in Training
Penalty
Summary
The facility failed to ensure that residents are free from significant medication errors, as evidenced by the case of a resident who was administered incorrect medications. The resident, who had diagnoses including hypertension, acute kidney failure, acute pyelonephritis, and chronic obstructive pulmonary disease, was given medications that were not prescribed to them. These medications included Aspirin, Duloxetine, Linezolid, Oxycontin ER, and Metoprolol Succinate ER, along with an incorrect dosage of Flomax. This error occurred due to a nurse in training administering another resident's medications to the affected resident. The incident was reported to the Rhode Island Department of Health, and it was noted that the resident experienced dizziness and a significant drop in blood pressure following the medication error. The resident's blood pressure readings fluctuated throughout the day, and the resident also reported abdominal discomfort and a lack of appetite. Despite these symptoms, the resident remained alert and oriented, and the Nurse Practitioner recommended hospital evaluation, which was declined by the resident and their family. Interviews with facility staff, including the Unit Supervisor and the Director of Nursing Services, confirmed that the medication error was identified promptly, and the Nurse Practitioner was contacted immediately. The nurse who administered the incorrect medications stayed with the resident for the rest of the shift to monitor their condition. However, the facility failed to provide evidence that the resident was free from significant medication errors or that the facility's medication administration policy was followed correctly.
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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