Lincolnwood Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in North Providence, Rhode Island.
- Location
- 610 Smithfield Road, North Providence, Rhode Island 02904
- CMS Provider Number
- 415035
- Inspections on file
- 60
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 7 (2 serious)
Citation history
Health deficiencies cited at Lincolnwood Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility did not ensure that food and nutrition service personnel had the required Food Manager's Certification during all meal preparation and service times. Surveyors found that cooks in charge of preparing and serving meals held only Food Handlers Certifications, while the FDA Food Code requires the person in charge to be a certified Food Protection Manager. Review of dietary schedules showed multiple dates when no certified Food Manager was present during breakfast, lunch, or dinner, and the FSD acknowledged that only half of the cooks were certified and that there were scheduled periods without certified coverage.
Surveyors found that the facility failed to implement Enhanced Barrier Precautions (EBP) in accordance with CDC guidance and facility policy for two residents who had central venous catheters (CVCs) for in-house dialysis. Both residents had physician orders for regular monitoring of their right chest CVC access sites and dressings, but there were no EBP orders in their records. In one case, EBP signage and PPE were posted at the room entrance, but a regional clinical leader stopped the use of PPE and stated the resident did not require EBP, explaining the setup was for an anticipated new admission. In an interview, the Regional Director of Clinical Services acknowledged that the facility does not follow EBP for residents with CVCs for dialysis, despite CDC recommendations that residents with indwelling medical devices, including central lines, be placed on EBP.
A resident with a history of smoking and falls, while on oxygen therapy, was able to use a personal lighter in their room, resulting in the ignition of oxygen tubing and a minor fire that damaged the floor and equipment. The facility was aware of the resident's risk factors but did not provide evidence of adequate supervision or environmental safeguards to prevent this accident.
A resident was not protected from a significant medication error due to a failure in the medication administration process.
A resident was admitted without a doctor's order and was not under a physician's care at the time of admission, as required. The facility did not follow the necessary procedures to ensure medical oversight upon admission.
A resident with end stage renal disease was admitted with a physician's order for Miralax to be given as needed (PRN), but due to a transcription error by an LPN, the medication was administered daily instead. The resident, who was cognitively intact, reported never having taken the medication daily before and did not request the change. Staff interviews confirmed the error, and facility leadership could not provide evidence that the medication was given as ordered.
A resident with end stage renal disease requiring dialysis did not have their total daily fluid intake documented as ordered, with only nursing fluids recorded and no evidence of full compliance with a 1000 ml fluid restriction. Additionally, Sevelamer Carbonate, prescribed to be given with meals, was not administered on several dialysis days due to the resident's absence, and the provider was not notified of these missed doses. Facility staff and leadership were unable to provide evidence that physician's orders for fluid restriction and medication administration were followed.
A resident with paraplegia, dependent on two staff for transfers and requiring a mechanical lift, fell during a transfer when a sling strap slipped off the Hoyer lift. The resident sustained a femur fracture and a sacral fracture after striking the lift, with staff and the resident confirming the strap was not properly secured. Facility leadership could not provide evidence of a safe transfer or a resident interview following the incident.
The facility failed to maintain an effective infection prevention and control program, with staff not adhering to PPE protocols for residents on droplet precautions. A resident with Flu A had staff enter without proper PPE, and another with COVID-19 had staff enter without eye protection. Additionally, a resident with a PICC line had a nurse touch the dressing without gloves, breaching infection control practices.
The facility failed to implement an antibiotic stewardship program, as evidenced by the lack of antibiotic reviews or time-outs for residents prescribed antibiotics. An Infection Preventionist confirmed that the facility did not conduct antibiotic time-outs, indicating a systemic issue in infection control.
A resident with a PICC line had a dressing improperly managed by an LPN, who attempted to remove it with soiled gloves and re-secure it without gloves, breaching sterile procedure. The LPN acknowledged the error, and the DON confirmed the improper actions.
A facility failed to follow physician orders for a resident's wound care, resulting in a soiled dressing and improper documentation. The resident, with Alzheimer's and adult failure to thrive, had a wound dressing that was not changed daily as ordered. Observations revealed crusted drainage and an embedded dressing, contrary to the documented treatment. Interviews confirmed the discrepancy between the documented and actual care provided.
A resident admitted with a pressure ulcer on the coccyx did not receive timely assessment and documentation of the wound. The facility failed to measure or describe the ulcer upon admission, with documentation only occurring a week later. The resident's care plan included interventions for wound assessment, but these were not implemented promptly, as confirmed by the DON.
A resident experienced significant weight loss, and the facility failed to follow its policy for re-weighing and notifying the dietician. Despite the resident's severe weight loss, no interventions were implemented, and the dietician was not re-evaluated after the weight discrepancies. Staff interviews confirmed the oversight in following the facility's policy.
A facility failed to ensure proper bed elevation for a resident receiving continuous G-tube feeding, risking aspiration. Despite a care plan and physician's order to keep the bed elevated at 30-45 degrees, surveyors observed the bed not elevated during feeding. Staff acknowledged the oversight, and the resident was seen coughing, indicating potential aspiration risk.
A resident with Alzheimer's and adult failure to thrive had a soiled wound dressing that was not changed as per physician's orders. The TAR was inaccurately signed off by LPNs as if the treatment was completed. Interviews revealed the LPNs did not perform the treatment and were unaware of the dressing's date. The DON confirmed the TAR should not be signed off if treatment was not completed.
A resident was discharged with another resident's medications due to a failure in medication reconciliation by an LPN. The error was discovered when a home care nurse reviewed the medications, finding that the discharged resident had taken Atorvastatin, which was not prescribed to them. The DON could not explain the lack of reconciliation or discharge instructions, posing a risk of serious harm.
A resident with atrial fibrillation and pneumonia did not receive prescribed doses of Cefpodoxime due to staff oversight. The medication was available, but the responsible nurse failed to administer it and did not inform the provider of the missed doses. The DON and the resident's physician were unaware of the issue, highlighting a lapse in communication and adherence to medical orders.
A resident at high risk for falls, requiring two-person assistance for bed mobility, fell and sustained head injuries due to inadequate supervision. Only one NA was present during care, unaware of the two-person requirement, as indicated in the care plan and Kardex. Staff interviews revealed communication errors regarding the resident's care needs.
The facility failed to monitor and record intake and output for two residents with catheters, as required by their care plans. One resident had a suprapubic catheter and was readmitted with a urinary tract infection, while the other had a foley catheter and was readmitted with chronic kidney disease. The Director of Nursing Services acknowledged the lack of documentation during a surveyor interview.
A resident was transferred to a hospital without immediate notification to their family, as required. The resident, who had conditions including a urinary tract infection and MRSA, was sent to the hospital due to no urinary output and abdominal pain. The family was not informed until a day later, and the facility staff could not provide evidence of timely notification.
A resident received their roommate's medications, including hydralazine and labetalol, due to a failure to perform the required five checks. This error resulted in the resident experiencing hypotension, although they were asymptomatic. The incident was acknowledged by the DON, and the resident required IV fluids to address the low blood pressure.
A resident with Alzheimer's was transferred to a hospital due to aggressive behavior, and the facility failed to provide written notice of the bed-hold policy to the resident or their representative. Despite the resident's long-term stay, the facility informed the hospital that no beds were available upon discharge. Interviews revealed a lack of communication and documentation regarding the bed-hold policy, resulting in the resident's room being packed up and no bed available for their return.
A resident with heart failure, end-stage renal disease, and diabetes missed a critical cardiology appointment due to the facility's failure to arrange transportation. Despite orders for follow-up with hematology and a GI consult, these appointments were not scheduled. The cardiology office's attempts to reschedule were unanswered, and staff interviews confirmed the lack of action.
A resident with brain cancer did not receive the correct dosage of chemotherapy medication due to a transcription error by an LPN and a failure by the Pharmacy Consultant to identify the discrepancy during a Medication Regimen Review. The resident was supposed to receive 125 mg of Temozolomide daily but only received 5 mg, as the LPN inaccurately transcribed the order and did not reconcile it with hospital records.
A resident with brain cancer received incorrect chemotherapy dosage and form due to transcription and administration errors. The LPN failed to reconcile hospital discharge orders with the facility's MAR, leading to the resident receiving only 5 mg of Temozolomide instead of the prescribed 125 mg. Additionally, the medication was improperly administered by opening capsules, contrary to guidelines requiring them to be swallowed whole.
A resident with intact cognition was injured after being pushed by another resident with severe cognitive impairment, leading to a hip fracture. The aggressive resident had a history of disruptive behaviors, and the facility failed to implement effective interventions to prevent the altercation, resulting in a deficiency in protecting residents from abuse.
A resident's dignity was compromised when a Nursing Assistant (NA) called them a 'cripple' during care. Despite being instructed to avoid the resident's room, the NA entered twice afterward, leaving the resident feeling degraded and upset. The Director of Nursing Services could not provide evidence that the NA was kept away from the resident as directed.
Lack of Certified Food Protection Manager Coverage During Meal Service
Penalty
Summary
The facility failed to ensure that support personnel in the food and nutrition services possessed the required competencies and credentials to safely carry out their duties, specifically by not having a certified Food Protection Manager in charge during all meal preparation and service times. Surveyors reviewed the 2022 FDA Food Code, Section 2-102.11, which requires the person in charge to be a certified Food Protection Manager who has passed an accredited program. During an initial kitchen tour, a cook identified as the staff member in charge of food service for the breakfast meal, and the Food Service Director (FSD) later confirmed that the two cooks who prepared and served that breakfast only held Food Handlers Certifications, not Food Manager's Certifications. Further record review of dietary schedules for February and March 2026 showed multiple dates on which no staff member with a Food Manager's Certification was scheduled during one or more of the three daily meals, despite prepared meals being delivered to units during defined breakfast, lunch, and dinner timeframes. The FSD, in the presence of the Regional FSD, acknowledged that only 2 of the 4 cooks on staff had obtained the required Food Manager's Certification and that the facility's staffing schedules included periods when no certified Food Manager was present during meal preparation and service. This lack of appropriately certified personnel during active food preparation and service constituted the deficiency identified by surveyors.
Failure to Implement Enhanced Barrier Precautions for Dialysis Residents with Central Lines
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program consistent with CDC guidance and its own policy regarding Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices, specifically central venous catheters (CVCs) used for dialysis. CDC guidance dated June 28, 2024, states that EBP, including gown and glove use during high-contact resident care activities, should be implemented for residents with wounds or indwelling medical devices such as central lines, and that these precautions should remain in place for the duration of the device. The facility’s written EBP policy acknowledges that indwelling medical devices include central lines, but further review showed the facility does not place residents on EBP when they have a central line for dialysis, which is not aligned with CDC guidance. For one resident admitted in December 2021 with end stage renal disease and dependent on in-house dialysis three times weekly, physician orders included monitoring the right chest CVC access site every shift for signs of infection and documenting abnormal findings, but there was no order for EBP despite the presence of the indwelling CVC. Surveyor observation of this resident’s room showed EBP signage and a PPE bin at the entrance, but the Regional Director of Clinical Services stopped the surveyor from donning PPE and stated the resident did not require EBP, explaining the signage and bin were placed in anticipation of a new admission. For a second resident admitted in June 2025 with Parkinson’s disease and dependent on in-house dialysis three times weekly, orders included monitoring the right chest CVC site and dressing every shift, but again there was no EBP order. In an interview, the Regional Director of Clinical Services confirmed that the facility does not follow EBP for residents with a CVC for dialysis, despite acknowledging CDC’s recommendation for EBP for residents with indwelling medical devices, including central lines.
Failure to Prevent Accident Hazard Involving Oxygen and Smoking Materials
Penalty
Summary
A deficiency occurred when the facility failed to provide an environment free from accident hazards and did not ensure adequate supervision to prevent accidents for a newly admitted resident. The resident, who had a history of smoking, multiple rib fractures, and falls, was admitted with these risk factors known to the facility. Despite this, the resident was able to access and use a personal lighter in their room while on oxygen therapy. This resulted in the resident accidentally igniting their oxygen tubing, causing a minor fire that damaged the floor and the oxygen concentrator. Surveyor observations confirmed physical evidence of the incident, including a discolored area on the floor and photographic documentation of burnt oxygen tubing and burn marks on the oxygen concentrator. Interviews with facility leadership revealed that the facility was aware of the resident's smoking history at admission but could not provide evidence that appropriate measures were taken to minimize accident hazards or provide adequate supervision. The resident confirmed using the lighter to find shoes in the dark, which led to the fire.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or inactions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Obtain Physician Order and Oversight at Admission
Penalty
Summary
A deficiency was identified when a resident was admitted without obtaining a doctor's order for admission and without ensuring the resident was under a physician's care. The required process to secure a physician's order and oversight at the time of admission was not followed, resulting in the resident not being under a doctor's care as mandated.
Failure to Follow Physician's Orders for PRN Medication Administration
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease and dependence on renal dialysis was admitted to the facility with a physician's order for Polyethylene Glycol 3350 (Miralax) to be administered as needed (PRN) for constipation, with instructions to hold for loose stools. Upon review, it was found that the order was incorrectly transcribed by an LPN as a daily medication rather than PRN, resulting in the resident receiving Miralax every morning from admission until the order was discontinued. The resident, who was cognitively intact, reported that they had never taken Miralax daily prior to admission and had not requested the medication to be changed to a daily order. Interviews with staff confirmed the transcription error, and there was no documentation to support that the physician's original PRN order had been changed to daily. The facility's leadership was unable to provide evidence that the medication was administered according to the physician's order during the specified period. The progress notes also did not indicate any provider-initiated change to the medication order upon admission.
Failure to Document Fluid Restriction and Administer Prescribed Medication for Dialysis Resident
Penalty
Summary
The facility failed to ensure that a resident with end stage renal disease and dependent on renal dialysis received care and services consistent with physician's orders and professional standards. Specifically, the resident had a physician's order for a 1000 ml daily fluid restriction, with detailed breakdowns for nursing and dietary fluid allowances, and required documentation of total fluid intake each shift. However, from 7/7/2025 to 7/17/2025, only nursing fluid intake was documented, and there was no evidence of total daily fluid intake being recorded. Staff interviews confirmed that intake and output were not documented, and the facility was unable to provide evidence that the fluid restriction was followed as ordered. Additionally, the resident had a physician's order for Sevelamer Carbonate 800 mg three times daily with meals to manage high blood phosphorus levels. On multiple dialysis days, the medication was not administered as ordered because the resident was absent from the facility for dialysis during scheduled administration times. The medication was not given after the resident returned, and there was no documentation that the provider was notified of the missed doses. Staff acknowledged the missed administrations and the lack of provider notification, and facility leadership could not provide evidence that the resident received the medication as ordered.
Resident Fall Due to Improperly Secured Mechanical Lift Sling
Penalty
Summary
A deficiency occurred when a resident with paraplegia, who required extensive assistance and the use of a mechanical lift for transfers, sustained a fall during a transfer from bed to wheelchair. The incident happened when staff were using a Hoyer lift and one of the sling straps slipped off or became unattached, causing the resident to fall from a height. The resident's leg struck the mechanical lift during the fall, resulting in a left femur fracture and a nondisplaced left sacral alar fracture, which required hospitalization and surgical intervention. Record reviews revealed that the resident was cognitively intact and dependent on two staff for transfers, as documented in the care plan and Minimum Data Set (MDS) assessment. The facility's policy on mechanical lifts required staff to securely attach sling straps according to the manufacturer's instructions and double-check their security before lifting the resident. However, staff interviews and progress notes confirmed that the sling was not properly secured, leading to the strap slipping off during the transfer. Both staff involved in the transfer and the resident confirmed that the fall occurred due to the strap becoming unattached while the resident was suspended in the lift. Further investigation showed that facility leadership, including the Director of Nursing Services (DNS) and the Administrator, were not present during the incident and could not provide evidence that the transfer was performed safely or that the resident was interviewed for a detailed account of the event. The lack of proper securing of the sling and failure to ensure adherence to established transfer protocols directly led to the resident's fall and subsequent injury.
Infection Control Deficiencies in PPE Compliance
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to required personal protective equipment (PPE) protocols for residents on droplet precautions. Resident ID #5, who was readmitted with end-stage renal disease and tested positive for Flu A, was observed by a surveyor when a nursing assistant entered the room without wearing the required gown, gloves, or eye protection, despite the posted signage indicating these precautions. Similarly, Resident ID #29, diagnosed with dementia and also positive for Flu A, had staff entering the room without proper PPE, including a certified medication technician who did not wear a gown, gloves, or eye protection. Further deficiencies were noted with Resident ID #106, who tested positive for COVID-19. Staff were observed entering the resident's room without eye protection, and one staff member exited the room without removing PPE, subsequently contaminating clean linens. Resident ID #107, also COVID-19 positive, had a hospice provider in the room without a gown or eye protection, unaware of the necessary precautions. These observations indicate a systemic issue with staff compliance to infection control protocols, as confirmed by interviews with staff and the infection preventionist. Additionally, the facility failed to adhere to enhanced barrier precautions for Resident ID #416, who had a PICC line due to osteomyelitis and gangrene. A licensed practical nurse was observed touching the PICC line dressing with ungloved hands, contrary to the posted precautions requiring gown and gloves during device care. This lapse was acknowledged by both the nurse involved and the Director of Nursing Services, highlighting a breach in infection control practices for residents with invasive devices.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an 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 three residents who were prescribed antibiotics without evidence of an antibiotic review or time-out. Resident ID #15 was readmitted with chronic obstructive pulmonary disorder and type II diabetes mellitus and was prescribed Levaquin for a cough. Resident ID #32, with chronic kidney disease and bipolar disorder, was prescribed Amoxicillin for a dental infection. Resident ID #53, diagnosed with Parkinson's disease and dementia, was prescribed Cephtriaxone for pneumonia. In all cases, there was no documentation of an antibiotic review or time-out. During an interview, the Infection Preventionist acknowledged that antibiotic time-outs were not completed for the residents receiving antibiotics. Furthermore, it was confirmed that the facility was not conducting antibiotic time-outs for any residents prescribed antibiotics. This lack of adherence to the CDC's recommended practices for antibiotic stewardship indicates a systemic issue in the facility's infection control program.
Improper PICC Line Dressing Change Procedure
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice concerning the care of a peripherally inserted central catheter (PICC line). The deficiency was identified during a surveyor observation where a resident with a PICC line had a dressing dated the same day, with gauze under the transparent dressing covering the insertion site. This setup made it difficult to assess for signs and symptoms of infection, which is contrary to the facility's policy and professional standards that require maintaining a sterile dressing for all peripheral catheter sites. During the observation, a Licensed Practical Nurse (LPN), identified as Staff A, was seen attempting to remove the PICC line dressing with soiled gloves, which she acknowledged was inappropriate. She also attempted to re-secure the dressing with ungloved hands, further breaching sterile procedure. Staff A admitted that changing a PICC line dressing is a sterile procedure and acknowledged her failure to maintain a sterile field or use sterile gloves. The Director of Nursing Services confirmed that Staff A's actions were incorrect, as she should not have attempted to remove the dressing with soiled gloves or without wearing gloves.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding the adherence to physician orders for wound care. Resident ID #79, who was readmitted to the facility with diagnoses including Alzheimer's disease and adult failure to thrive, was observed with a wound dressing on the back of the right hand that was visibly soiled and dated several days prior. The physician's order required daily cleansing and dressing of the wound, which was documented as completed on the Treatment Administration Record (TAR) for several consecutive days. However, during a surveyor observation, it was found that the dressing had not been changed as per the physician's order, as evidenced by the presence of dark, crusted drainage and an embedded dressing that required soaking for removal. Interviews with the LPN and the Director of Nursing Services confirmed that the treatment was not performed as documented, and the TAR should not have been signed off as completed. The Nurse Practitioner also expressed the expectation that the treatment should have been completed as ordered until the wound healed.
Failure to Timely Assess and Document Pressure Ulcer
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with a pressure ulcer, consistent with professional standards of practice. The resident, who was admitted with a pressure ulcer on the coccyx, did not have the wound measured or described upon admission. The initial assessment lacked details such as measurements, staging, exudate, pain, and the condition of the wound bed or edges. This lack of documentation persisted until a week after admission, when a Weekly Wound Progress Report finally recorded the wound's measurements. The resident was admitted with conditions including hemiparesis and hemiplegia, which increased the risk of pressure ulcer development due to immobility. The admission care plan identified the pressure ulcer as unstageable and included interventions for wound measurement and assessment. However, these interventions were not implemented in a timely manner, as evidenced by the absence of documentation until seven days post-admission. The Director of Nursing Services confirmed the lack of evidence for timely wound assessment during a surveyor interview.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, resulting in significant weight loss. The resident, who was readmitted to the facility with diagnoses including dementia and vitamin D deficiency, experienced severe weight loss over several months. The facility's policy required re-weighing the resident the next day for confirmation of any weight change of 5% or more, and notifying the dietician in writing if the weight was verified. However, the record review revealed that the resident was not re-weighed promptly after experiencing severe weight loss, and the dietician was not notified as required by the facility's policy. The resident's care plan included monitoring and reporting significant weight loss, but the facility failed to implement interventions after the resident experienced a severe weight loss of 19.5 lbs. (14.27%) from October 1, 2024, to January 9, 2025. The resident was last evaluated by the dietician on October 7, 2024, and had not been re-evaluated since the weight discrepancies were noted. Interviews with staff confirmed that the resident should have been re-weighed and that the dietician and provider should have been notified to implement interventions, but these actions were not taken.
Failure to Maintain Proper Bed Elevation During Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving continuous feeding via a gastrostomy tube (G-tube) was properly positioned to prevent complications such as aspiration. The resident, who was admitted with diagnoses including dysphagia and cognitive communication deficit, had a care plan in place to remain free from complications. A physician's order specified that the head of the resident's bed should be elevated to 30-45 degrees during feeding, flushing, and medication administration to prevent aspiration. During surveyor observations, it was noted that the resident's bed was not elevated to the required position while the enteral feeding was running. On two separate occasions, staff members, including a Speech Therapist and a Nursing Assistant, acknowledged the failure to maintain the correct bed elevation. The resident was observed coughing during one of these instances, indicating a potential risk of aspiration. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing Services, confirmed the requirement for bed elevation during feeding to prevent aspiration, highlighting the facility's failure to adhere to the prescribed care plan.
Failure to Maintain Accurate Medical Records for Wound Care
Penalty
Summary
The facility failed to maintain the medical record of a resident in accordance with accepted professional standards and practices. The resident, who was readmitted to the facility with diagnoses including Alzheimer's disease and adult failure to thrive, was observed with a wound dressing on the back of the right hand that was visibly soiled and dated several days prior. The physician's order required daily cleansing and dressing of the wound, but the Treatment Administration Record (TAR) indicated that the treatment was signed off as completed on multiple days by different LPNs, despite the dressing not being changed. Interviews with the involved staff revealed that the LPNs signed off on the wound treatment without actually performing it, and they were unaware of the dressing's date. The Director of Nursing Services confirmed that the TAR should not be signed off if the treatment was not completed. This discrepancy in record-keeping and treatment administration led to the deficiency being identified during the survey.
Medication Reconciliation Failure at Discharge
Penalty
Summary
The facility failed to properly reconcile medications for a resident being discharged, leading to a significant medication error. Resident ID #1, who had been admitted with serious health conditions including liver cell carcinoma and end-stage renal disease, was discharged with medications belonging to another resident, Resident ID #2. This error was discovered when a home care agency nurse reviewed the medications and found that Resident ID #1 had been given Atorvastatin, Lisinopril, and Amlodipine, which were prescribed for Resident ID #2. As a result, Resident ID #1 mistakenly took Atorvastatin on two separate occasions after discharge. The investigation revealed that the Licensed Practical Nurse involved in the discharge process did not verify the medications placed in the discharge bag and failed to provide medication instructions to Resident ID #1 or their family. The discharge paperwork also lacked any medication orders or instructions. The Director of Nursing Services could not explain why the medication reconciliation was not completed, nor why discharge instructions were not provided. This oversight placed residents at risk for serious harm, as noted in the report.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by not following a physician's orders for a resident. The resident, who was admitted with diagnoses including atrial fibrillation and pneumonia, had a physician's order to receive Cefpodoxime, an antibiotic, twice a day for three days. However, the medication was not administered as ordered on three occasions, specifically missing doses on two separate days. Interviews with staff revealed that the medication was available in the facility's automated dispensing system, yet it was not given to the resident. The nurse responsible for the resident on one of the days admitted to not administering the medication and failing to notify the provider of the missed doses. The Director of Nursing Services and the resident's physician were also unaware of the missed doses, indicating a breakdown in communication and adherence to medical orders within the facility.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure a safe environment for a resident at high risk for falls, resulting in a witnessed fall and subsequent injury. The resident, who was readmitted with a diagnosis including dementia, was assessed as requiring assistance from two staff members for bed mobility and turning. However, during an incident, only one Certified Nursing Assistant (NA) was present, and while providing care, the resident fell, sustaining head lacerations. The NA was unaware of the requirement for two staff members to assist the resident, as indicated in the resident's care plan and Kardex. Interviews with staff revealed discrepancies in the communication and understanding of the resident's care needs. The NA admitted to being unaware of the two-person assistance requirement, while a Licensed Practical Nurse (LPN) confirmed that the Kardex indicated the need for two staff members. The Director of Nursing Services acknowledged that the assessment tool and care plan were in error, leading to the misunderstanding of the resident's care requirements. This oversight resulted in inadequate supervision and a hazardous environment, contributing to the resident's fall and injuries.
Failure to Monitor and Record Catheter Care
Penalty
Summary
The facility failed to ensure that a resident with a suprapubic catheter received treatment and care in accordance with professional standards of practice. Resident ID #3, who was readmitted to the facility with diagnoses including urinary tract infection, anemia, and MRSA, had a care plan that required monitoring and recording of intake and output every 8 hours. However, the record review revealed no evidence that the facility was adhering to this standard. Additionally, the care plan required monitoring of urinary frequency, which was also not documented. During an interview, the Director of Nursing Services acknowledged the lack of monitoring and recording for this resident. Similarly, the facility did not provide appropriate care for Resident ID #4, who had a foley catheter and was readmitted with chronic kidney disease and dementia. The care plan for this resident also required monitoring and recording of intake and output every 8 hours, as well as monitoring urinary frequency. The record review showed no evidence of compliance with these requirements. During a surveyor interview, the Director of Nursing Services, along with the Administrator and Regional Nurse, could not explain why the facility failed to document the intake and output for both residents.
Failure to Notify Family of Hospital Transfer
Penalty
Summary
The facility failed to immediately inform the resident's representative about the decision to transfer a resident to an acute care hospital. The deficiency was identified during a review of a community-reported complaint submitted to the Rhode Island Department of Health. The complaint alleged that the resident was transferred to a hospital without notifying the family. The resident, who had been readmitted to the facility with diagnoses including urinary tract infection, anemia, and MRSA, was noted to have no urinary output and was complaining of abdominal pain. Consequently, the resident was sent to the hospital per the provider's order. However, there was no evidence in the nursing progress notes that the family was informed of this transfer. Further investigation revealed that the resident's daughter only learned of the hospital transfer during a conversation about the resident's positive MRSA test results, a day after the transfer. The resident's son was also not informed until five days later when contacted about holding the resident's bed. Interviews with staff, including the LPN who obtained the transfer order, failed to provide evidence that the family was notified at the time of the transfer. The LPN could not recall who was informed, and the Director of Nursing Services, Administrator, and Regional Nurse were unable to provide evidence of notification to the family.
Medication Error Leads to Hypotension in Resident
Penalty
Summary
The facility failed to ensure that all residents are free from significant medication errors, as evidenced by an incident involving a resident who received another resident's medications. The resident, admitted in August 2024 with diagnoses including pneumonia and abnormal weight loss, was mistakenly given their roommate's medications on 8/9/2024. This error was documented in a progress note and a Full QA Report, which indicated that the nurse did not perform the required five checks, leading to the administration of hydralazine 50 mg and labetalol 200 mg, both used to treat high blood pressure, to the wrong resident. As a result of this medication error, the resident experienced hypotension, or low blood pressure, although they remained asymptomatic. The incident was reported to the nurse practitioner, and new orders were issued to monitor the resident's blood pressure. The Director of Nursing Services acknowledged the error during a surveyor interview, confirming that the resident required intravenous fluids due to the low blood pressure caused by the medication error.
Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
The facility failed to provide written notice of the bed-hold policy to a resident or their representative prior to the resident's transfer to the hospital. The resident, who had been living in the facility for two years and had a diagnosis of Alzheimer's disease, was sent to the hospital due to aggressive behavior. Despite the resident's long-term stay, the facility informed the hospital case manager that the resident was considered short-term and that no beds were available upon the resident's discharge from the hospital. The facility did not respond to the hospital's attempts to coordinate the resident's return, and the resident's daughter was not informed of the bed-hold policy either verbally or in writing. Interviews with facility staff, including the DNS, Admissions Director, and Administrator, revealed a lack of communication and documentation regarding the bed-hold policy. The DNS admitted to not discussing the policy with the resident's daughter, and the Admissions Director acknowledged not providing the required written notice. The Administrator was unable to provide evidence of any written notice being given and was unaware of any contact made with the resident's daughter. Consequently, the resident's room was packed up, and the facility did not have a bed available for the resident's return.
Failure to Schedule and Facilitate Specialist Appointments
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 orders for obtaining appointments with specialists. The resident, who was admitted in July 2024 with diagnoses including heart failure, end-stage renal disease, and diabetes, had several follow-up appointments scheduled, including a critical cardiology appointment. Despite the urgency, the facility did not arrange transportation for the resident to attend the cardiology appointment, and the resident missed it. The cardiology office attempted to contact the facility twice to reschedule, but no response was received. Additionally, a Nurse Practitioner had ordered follow-up appointments with hematology and a GI consult after reviewing the resident's critical BNP level, but there was no evidence that these appointments were scheduled. Interviews with the facility's staff, including the Director of Nursing Services, confirmed that the appointments were neither scheduled nor attempted to be scheduled, and no explanation was provided for the missed cardiology appointment. This lack of action resulted in the resident not receiving necessary specialist care as ordered.
Chemotherapy Dosage Error Due to Transcription and Review Failures
Penalty
Summary
The facility failed to provide accurate pharmaceutical services for a resident receiving chemotherapy medication. The resident, who was admitted with diagnoses including malignant neoplasm of the brain and bipolar disorder, was supposed to receive a daily dosage of 125 mg of Temozolomide. However, after being discharged from the hospital, the resident received only 5 mg daily from late July to early August, contrary to the prescribed 125 mg. This discrepancy arose because a Licensed Practical Nurse inaccurately transcribed the medication order as a taper instead of ensuring the total dosage equaled 125 mg. Additionally, the nurse did not reconcile the hospital's medication orders with the facility's Medication Administration Record (MAR) before the resident's hospitalization. The Pharmacy Consultant conducted a Medication Regimen Review on July 31 and failed to identify the discrepancy in the resident's chemotherapy medication dosage. During a surveyor interview, the Pharmacy Consultant acknowledged the oversight, admitting that the resident should have been on 125 mg of Temozolomide daily. This failure to identify and correct the medication error during the review process contributed to the resident not receiving the correct dosage of chemotherapy medication.
Medication Errors in Chemotherapy Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in administering the correct dosage and form of chemotherapy medication. The resident, who was admitted with diagnoses including malignant neoplasm of the brain and bipolar disorder, was supposed to receive Temozolomide at a dosage of 125 mg daily. However, due to an error in transcribing the medication order, the resident received only 5 mg daily for a period of time. This discrepancy was not identified because the Licensed Practical Nurse (LPN) did not reconcile the medication orders from the hospital with the facility's Medication Administration Record (MAR) upon the resident's readmission. The Director of Nursing Services (DNS) acknowledged the failure to follow the facility's policy for medication reconciliation. Additionally, the facility did not administer the chemotherapy medication in the correct form. The resident, who requires pureed food and crushed medications, was given Temozolomide capsules that were opened and administered contrary to the prescribing information, which states that the capsules should be swallowed whole. Both the Registered Nurse and the LPN involved confirmed that they administered the medication by opening the capsules, which was acknowledged as incorrect by the Nurse Practitioner. This practice was not aligned with the medication's prescribing guidelines, further contributing to the medication error.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an incident involving two residents that resulted in significant injury. Resident ID #1, who had intact cognition and required assistance for transfers and ambulation, was pushed by Resident ID #2, leading to a fall and a severe hip fracture. Resident ID #1 reported that Resident ID #2 entered their room, went through their belongings, and pushed them, causing the fall. This account was consistent with the observations of a Nursing Assistant who witnessed Resident ID #2 in Resident ID #1's room after hearing a loud thump. Resident ID #2, who had severe cognitive impairment due to Alzheimer's disease and dementia, had a history of disruptive and aggressive behaviors. The care plan for Resident ID #2 included interventions for managing these behaviors, such as redirection and monitoring. However, the facility did not effectively implement these interventions to prevent the altercation. Prior to the incident, Resident ID #2 had exhibited physical aggression towards staff and other residents, and the facility failed to provide sufficient protection to prevent resident-to-resident abuse. The facility's policy on abuse prevention emphasizes the protection of residents from abuse by anyone, including other residents. Despite this, the facility did not adequately assess the effectiveness of interventions for Resident ID #2's behaviors, nor did they provide immediate interventions to ensure the safety of other residents. The Director of Nursing Services acknowledged the lack of evidence that Resident ID #1 was kept free from abuse, highlighting a deficiency in the facility's ability to protect residents from harm.
Removal Plan
- The facility completed a Quality Assurance and Performance Improvement Plan to review the incident and identify areas of improvement.
- The facility completed an audit of current residents that exhibit aggressive behaviors, and they identified if the appropriate treatment is in place, that the provider is aware of the behaviors and that the family is in agreement with the plan of care.
- Education was provided to all staff on how to manage residents that exhibit aggressive behaviors.
- The perpetrator in this incident was placed on a 1:1 status. S/he will remain on a 1:1 until the interdisciplinary team reassesses the efficacy of the interventions.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure a resident's dignity was maintained for one of the residents reviewed. Nursing Assistant (NA), Staff A, allegedly called the resident a 'cripple' while providing care. The resident, who is cognitively intact with a Brief Interview for Mental Status score of 15 out of 15, reported feeling awful, angry, helpless, and degraded by the comment. The incident was corroborated by the resident's roommate and another NA, Staff B, who was present during the incident. Staff B also noted that the resident appeared visibly upset and requested not to be assisted by Staff A afterward. Despite the directive that Staff A should not be involved in the resident's care following the incident, there was evidence that Staff A entered the resident's room twice after the incident. The Director of Nursing Services was unable to provide evidence that Staff A was kept away from the resident's room as instructed. This failure to maintain the resident's dignity and adhere to the facility's policy on respectful communication constitutes a deficiency in care.
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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