Holiday Retirement Home Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Manville, Rhode Island.
- Location
- 30 Sayles Hill Road, Manville, Rhode Island 02838
- CMS Provider Number
- 415075
- Inspections on file
- 29
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Holiday Retirement Home Inc during CMS and state inspections, most recent first.
A resident with chronic inflammatory demyelinating polyneuropathy and lymphedema developed large bruises on the right upper buttock and later on the left proximal thigh, described as deep purple and measuring approximately 18 cm by 22 cm. Facility policy on abuse and injuries of unknown origin requires initiation of an investigation, obtaining witness statements, notifying administrative personnel, and documenting a comprehensive internal investigation in the clinical record. Record review showed no evidence that any investigation was conducted to determine the origin of either bruise, and the DON confirmed that while new bruising should be investigated and documented, he could not provide evidence that this was done in these instances.
Two residents did not receive care consistent with physician orders and professional standards. One resident with significant neuromuscular and edema-related conditions had an order requiring two staff members at all times for care, yet was showered by a hospice NA alone after being transferred with assistance, during which active bleeding occurred and a traumatic wound to the great toe was later documented. Another resident with a history of MI and stroke, on dual antiplatelet therapy with aspirin and Plavix, had a physician order for a cardiology consult prior to possible discontinuation of Plavix, but no evidence was found that the consult was scheduled, and the Scheduler reported being unaware of the need for the appointment.
Surveyors found that several residents did not receive care in accordance with physician orders and professional standards, including improper air mattress settings, incorrect oxygen administration, and failure to notify a physician of significant weight gain. Staff were unaware of correct procedures, and documentation did not reflect required notifications.
Nursing staff failed to accurately document and follow physician orders for several residents, including not verifying air mattress settings according to weight, not ensuring correct oxygen flow rates, and documenting encouragement of incentive spirometer use when the device was not present. Staff acknowledged documenting completion of these tasks without performing them, resulting in inaccurate medical records.
The facility did not conduct required antibiotic 'time outs' or reviews for three residents who were prescribed antibiotics for conditions such as a toe infection, a surgical incision, and pneumonia. Medical records lacked documentation of clinical reviews within the recommended timeframe, and the Infection Preventionist confirmed that no staff member was assigned to complete these reviews during her absence.
A resident with multiple chronic conditions was not assessed or monitored for respiratory status, edema, and congestion as ordered, despite exhibiting symptoms such as lower extremity swelling and a persistent cough. Staff failed to document required assessments, did not notify the physician of the change in condition in a timely manner, and only performed necessary evaluations after surveyor intervention. Facility policy requiring prompt notification and assessment was not followed.
A resident with a stage two pressure ulcer and orders for Enhanced Barrier Precautions did not receive care in accordance with infection control protocols. During wound care, an RN failed to don a gown before starting the procedure, placed soiled materials on the bedside table without disinfecting it, and exited the room wearing the gown. Additionally, two NAs performed a transfer using a Hoyer lift without wearing the required PPE, despite clear signage and orders. All involved staff acknowledged not following the EBP protocol.
The facility did not ensure that two residents' medical records included documentation of being offered, receiving, or refusing the updated pneumococcal vaccine (PCV20 or PCV21), despite prior vaccinations with PCV13 and PPSV23. Staff interviews confirmed the absence of this documentation, and the facility's vaccination policy was found to be outdated and not aligned with current CDC recommendations.
Surveyors observed that the main kitchen's walk-in freezer had significant ice buildup on the sprinkler head and fan, and a kitchenette microwave was severely cracked with peeling paint. The Food Service Director confirmed both issues during the inspection.
A resident with peripheral vascular disease was found to have severe foot wounds infested with maggots, indicating a failure in providing adequate foot care. Despite being dependent on staff for lower body dressing, the resident's wounds were not identified during routine assessments. An LPN noted significant wounds with maggots, but other staff failed to conduct thorough skin checks. The DON admitted the lack of preventive care protocols for residents prone to foot problems.
A facility failed to ensure nursing staff had the necessary competencies for conducting thorough skin assessments, leading to a resident being hospitalized with untreated foot wounds and maggots. The facility's policy required weekly skin assessments, but a nurse did not check between the resident's toes, missing the wounds. Six nursing staff members lacked competency-based training, and the facility did not follow its assessment plan, putting all residents at risk.
A facility failed to maintain accurate medical records for a resident, as a skin assessment did not identify foot wounds later found at a hospital. The RN admitted to not checking between the toes, and the DON confirmed this was expected. The facility could not prove the assessment was done accurately.
A facility failed to follow professional standards by not having a physician's order or documentation for a resident's Freestyle Libre sensor, a continuous glucose monitoring system. The resident, with diabetes and COPD, indicated the sensor should be changed every 14 days, but records lacked evidence of orders or change history. The DON confirmed the absence of necessary documentation and orders.
A resident with diabetes received incorrect insulin dosages on multiple occasions due to a failure to follow physician's orders. Despite blood sugar levels indicating the need for 35 units of Humalog Mix 75-25 insulin, only 25 units were administered. This error was acknowledged by the DON during a surveyor interview.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to investigate injuries of unknown origin for a resident who had significant bruising on two occasions. The facility’s abuse prohibition policy defines injuries of unknown origin and requires that an initial investigation be started, witness statements obtained, appropriate administrative personnel notified, and a comprehensive internal investigation carried out, with documentation in the clinical record. The resident, readmitted in July 2025, had diagnoses including chronic inflammatory demyelinating polyneuropathy and lymphedema. Progress notes showed that on 8/26/2025 a large bruise was noted on the right upper buttock, and on 9/8/2025 staff found a large, deep purple bruise on the left proximal thigh measuring approximately 18 cm by 22 cm during care at 12 AM. Further record review did not show any evidence that an investigation was conducted to determine the origin of either bruise. In an interview, the Director of Nursing Services stated that new bruising should trigger an investigation to determine etiology and be documented in the clinical record, but he was unable to provide evidence that such investigations were completed for the bruising documented on 8/26/2025 and 9/8/2025.
Failure to Follow Physician Orders for Two-Person Care and Cardiology Consult
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and professional standards of practice for two residents. One resident, readmitted in July 2025 with chronic inflammatory demyelinating polyneuropathy and lymphedema, had a physician’s order dated 7/10/2025 requiring two staff members at all times for resident care. On 8/27/2025 during the 7:00 AM to 3:00 PM shift, the resident was taken to the shower room by a facility NA and a hospice NA. The facility NA assisted with transferring the resident into the shower chair via a Hoyer lift along with the hospice NA, but the hospice NA then showered the resident alone. During the shower, the hospice NA observed active bleeding from an unidentified source, and when nursing staff arrived, a pool of blood was noted in the bathroom. A skin assessment revealed an open area with a split to the skin on the top of the right great toe, and progress notes documented a traumatic wound to the distal tip of the right great toe with copious blood drainage and active bleeding. The NA assigned to the resident stated she was not aware that the resident required two staff members for care at all times, and record review did not show evidence that two staff members were present for care during the shower as ordered. The second deficiency concerns a failure to carry out a physician’s order for a cardiology consult for another resident. This resident was readmitted in September 2025 with diagnoses including myocardial infarction and cerebral infarction and had existing physician’s orders for aspirin 81 mg daily and Plavix 75 mg daily. A progress note dated 10/30/2025 documented that the resident was on dual antiplatelet therapy with aspirin and Plavix, and the pharmacy recommended discontinuation of Plavix. This recommendation was reported to the physician, who issued a new order to obtain a cardiology consult prior to discontinuing the medication. A physician’s order dated 10/31/2025 directed staff to obtain a cardiology consult for possible discontinuation of Plavix. Record review failed to show evidence that a cardiology consult had been scheduled, and the Scheduler reported being unaware that the resident needed a cardiology appointment and had not reached out to schedule it.
Failure to Follow Physician Orders and Professional Standards of Care
Penalty
Summary
Surveyor observations, record reviews, and staff interviews revealed that the facility failed to ensure residents received care in accordance with professional standards and physician orders. Multiple residents with air mattresses had their mattress settings incorrectly adjusted, not matching either the physician's order or the resident's current weight. For example, one resident weighing 119.6 lbs had their air mattress set to 300 lbs, while another resident weighing 141 lbs had their mattress set to 350 lbs. Staff interviewed were unaware of the correct settings, and the Director of Nursing Services confirmed that the settings should have matched the residents' weights or the specific physician orders. Additionally, a resident with a physician's order for continuous oxygen at 2 liters per minute was observed receiving oxygen at 4 liters per minute on several occasions. Staff acknowledged that the oxygen was not being administered as ordered, and the DNS stated that the physician's order should have been followed regarding the oxygen flow rate. Another deficiency was identified for a resident with an order for daily weights three times per week, with instructions to notify the physician if there was a weight gain greater than 3 lbs in a day or 5 lbs in a week. The resident experienced a weight gain of 5.4 lbs in one week, but there was no evidence that the physician was notified as required. Staff interviews confirmed that the weight gain was not reported to the physician, and the nurse practitioner and DNS both indicated that notification should have occurred per the order.
Failure to Accurately Maintain Medical Records and Follow Physician Orders
Penalty
Summary
The facility failed to accurately maintain medical records and safeguard resident-identifiable information in accordance with accepted professional standards for several residents. For three residents with air mattresses, physician orders required that the mattress settings be checked every shift and set according to the resident's weight. However, surveyor observations revealed that the air mattresses were not set to the correct weights, and nursing staff documented in the Treatment Administration Record (TAR) that the checks were completed without verifying or adjusting the settings. Staff interviews confirmed that the documentation was completed without actually performing the required checks. For a resident receiving oxygen therapy, a physician's order specified oxygen at 2 liters per minute via nasal cannula continuously. Despite this, the resident was observed receiving oxygen at 4 liters per minute on multiple occasions. The Medication Administration Record (MAR) indicated that the resident was documented as receiving the ordered amount, but staff acknowledged that they signed off on the order without verifying the actual oxygen flow rate. Additionally, for a resident with an order to encourage the use of an incentive spirometer every shift, surveyors found that the device was not present in the resident's room during multiple observations. Despite this, the TAR reflected that staff had documented the order as completed. Staff interviews confirmed that documentation was made without ensuring the resident had access to or used the incentive spirometer.
Failure to Monitor and Review Antibiotic Use
Penalty
Summary
The facility failed to establish and implement an Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program with protocols and a system to monitor antibiotic use. Specifically, for three residents who were prescribed antibiotics for various conditions—including an infection of the great toe, a surgical incision, and pneumonia—there was no evidence in the medical records that an antibiotic 'time out' or review was conducted within 48 to 72 hours after the initiation of antibiotic therapy, as recommended by the CDC's Core Elements of Antibiotic Stewardship for Nursing Homes. Record reviews for these residents showed that antibiotics such as doxycycline and cephalexin were administered, but documentation of a clinical review to assess the appropriateness of the antibiotic, its dose, route, or duration was absent. During an interview, the Infection Preventionist confirmed that no antibiotic timeouts were completed for these residents and further disclosed that, during her leave of absence, there was no designated staff member responsible for completing these reviews.
Failure to Monitor and Notify Physician of Resident's Change in Condition
Penalty
Summary
A resident with a history of Alzheimer's disease, acute kidney failure, hypertensive heart disease, and chronic kidney disease was readmitted to the facility and had physician's orders in place for diuretic use, monitoring for edema, congestion, and weight changes every shift, as well as specific orders to assess and document respiratory status every shift for three days. Despite these orders, there was no evidence that the resident's respiratory status was assessed and documented as required on multiple shifts. Additionally, staff failed to monitor and document the presence of edema and congestion as ordered. Surveyor observations revealed that the resident exhibited swelling in the lower legs and a congested, non-productive cough over several days. Staff interviews confirmed that the resident was observed coughing, but assessments were not performed or documented, and the physician was not notified of the change in condition in a timely manner. One LPN admitted to documenting that an assessment was completed when it was not, and only assessed the resident for edema after the surveyor brought the issue to her attention. The resident was found to have severe pitting edema at that time. The facility's policy required notification of the physician and responsible party when a change in condition occurred, including the need to alter medical treatment. However, the physician was not notified of the resident's change in condition until several days after the initial assessment, and only after the surveyor intervened. Staff and leadership interviews confirmed that the expected standard of care was not met, as the resident was not assessed or monitored according to physician orders and professional standards of practice.
Failure to Follow Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as required by policy and physician orders, specifically regarding the use of Enhanced Barrier Precautions (EBP) for a resident with a stage two pressure ulcer. The resident, who was readmitted with muscle weakness and difficulty walking, had physician orders for EBP and wound care, including the use of gowns and gloves during high-contact care activities such as transfers and dressing changes. Despite clear signage and documented orders, staff did not consistently follow these protocols. During a wound dressing change, a registered nurse began the procedure without donning a gown, only putting it on after realizing the omission. The nurse also placed soiled dressing materials directly on the bedside table and failed to disinfect the area afterward. Additionally, the nurse exited the resident's room into the hallway while still wearing the gown, only returning to remove it after noticing the error. Further observations revealed that two nursing assistants entered the resident's room and performed a transfer using a Hoyer lift without wearing the required gown or gloves, despite the EBP signage and orders. Both nursing assistants acknowledged after the fact that they did not follow the EBP protocol. The staff educator confirmed that the expectation was for staff to adhere to infection control protocols and wear appropriate PPE as indicated by orders and signage. These actions and inactions directly led to the identified deficiency in the facility's infection prevention and control program.
Failure to Document and Update Pneumococcal Vaccination Practices
Penalty
Summary
The facility failed to ensure that residents' medical records included documentation indicating whether the pneumococcal vaccine (PCV20 or PCV21) was offered, received, or refused, or if there were medical contraindications. Specifically, for two residents who were readmitted to the facility, their immunization records showed they had previously received PCV13 and PPSV23 vaccines, but there was no evidence in their records regarding the offering or administration of the updated pneumococcal vaccines as recommended by current CDC guidelines. During staff interviews, the Infection Preventionist was unable to provide documentation that these residents had been offered or had declined the PCV20 or PCV21 vaccine. Additionally, the facility's policy on resident vaccination for flu and pneumonia was found to be outdated. The policy referenced guidelines from 2019 and did not include the most recent recommendations for pneumococcal immunizations. The Director of Nursing Services acknowledged during an interview that the current policy did not reflect the latest guidance, contributing to the lack of proper documentation and adherence to updated vaccination protocols.
Environmental Deficiencies in Kitchen and Kitchenette Areas
Penalty
Summary
Surveyor observations identified that the facility failed to maintain a safe, functional, and comfortable environment in both the main kitchen and one of three kitchenettes. In the main kitchen, the walk-in freezer was found to have an accumulation of ice buildup on the sprinkler head and the left fan near the ceiling, as confirmed by the Food Service Director (FSD) during the inspection. Additionally, in the Jamestown Unit Kitchenette, a microwave mounted above the counter was observed to be severely cracked with peeling paint on its exterior, which was also acknowledged by the FSD. These conditions were directly observed by surveyors and confirmed by staff interviews.
Failure to Provide Adequate Foot Care for Resident with Peripheral Vascular Disease
Penalty
Summary
The facility failed to provide appropriate foot care and treatment for a resident with peripheral vascular disease, leading to severe complications. The resident was readmitted to the facility with diagnoses including cellulitis and peripheral vascular disease. A complaint was reported to the Rhode Island Department of Health, alleging that the resident was treated at a hospital for multiple foot wounds infested with maggots. Hospital records confirmed the presence of wounds with black tissue and maggots, and the resident was admitted with cellulitis and started on intravenous antibiotics. The facility's staff failed to conduct thorough skin assessments, as evidenced by a registered nurse who did not inspect between the resident's toes. A nursing assistant also did not notice any wounds during a shower. However, an LPN observed a significant wound with moving maggots and redness on the resident's leg, indicating a lack of consistent and comprehensive foot care. The Director of Nursing Services acknowledged the expectation for full skin assessments, including between toes, and admitted the absence of standing orders for preventive foot care for residents with diabetes and circulatory disorders.
Inadequate Skin Assessment Competency Among Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to conduct thorough skin assessments, which compromised resident safety and well-being. A review of the facility's policy on skin care indicated that weekly skin assessments were required for every resident. However, a community-reported complaint revealed that a resident was hospitalized with multiple wounds on their feet, including maggots, which were not identified during a skin assessment conducted by a registered nurse the day before hospitalization. The nurse admitted to not checking between the resident's toes, where the wounds were located. Further investigation showed that six licensed nursing staff members lacked evidence of competency-based training on skin assessments. Interviews with the Director of Nursing Services and the Assistant Director of Nursing confirmed that the facility did not provide such training, nor did they follow their facility assessment regarding competency-based training. This oversight placed all 150 residents requiring weekly skin assessments at risk for serious injury, harm, impairment, or death.
Incomplete Skin Assessment Leads to Deficiency
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding skin assessments. A community-reported complaint alleged that a resident was treated at a hospital for multiple wounds on their feet that contained maggots. Hospital records from the admission on 8/4/2024 indicated the presence of wounds with black tissue and maggots between the toes, as well as cellulitis in the right lower extremity, necessitating intravenous antibiotics. However, a skin assessment conducted by a registered nurse on 8/3/2024, the day before the hospitalization, only noted dry skin on the resident's lower extremities and did not identify any foot wounds. During an interview, the registered nurse admitted to not examining the skin between the resident's toes during the assessment. The Director of Nursing Services confirmed that the nursing staff is expected to assess the skin between a resident's toes during skin assessments. The facility was unable to provide evidence that the skin assessment for the resident was completed accurately, leading to the deficiency in maintaining proper medical records.
Failure to Follow Physician's Orders for Glucose Monitoring
Penalty
Summary
The facility failed to meet professional standards of quality by not following physician's orders for a resident using a Freestyle Libre sensor, a continuous glucose monitoring system. The resident, who was admitted with diagnoses including diabetes and chronic obstructive pulmonary disease, reported that the sensor needs to be changed every 14 days. However, the record review did not show any evidence of a physician's order for the sensor or documentation indicating when it should be changed or when it was last changed. During an interview, the Director of Nursing Services was unable to provide documentation of the sensor's presence, the schedule for changing it, or the last change date, and acknowledged that there should be a physician's order for the sensor and its replacement schedule.
Medication Error in Insulin Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of insulin. The resident, who was admitted in April 2024 with diagnoses including diabetes and chronic obstructive pulmonary disease, had a physician's order for Humalog Mix 75-25 insulin with specific instructions based on blood sugar levels. The order specified administering 25 units if blood sugar was less than 150 and 35 units if it was above 150. However, on multiple occasions in April and May 2024, the resident's blood sugar was recorded as greater than 150, yet only 25 units of insulin were administered instead of the prescribed 35 units. This error was acknowledged by the Director of Nursing Services during a surveyor interview, who confirmed that the resident received the incorrect insulin dosage on the specified dates.
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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