Mansion Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Central Falls, Rhode Island.
- Location
- 104 Clay Street, Central Falls, Rhode Island 02863
- CMS Provider Number
- 415097
- Inspections on file
- 25
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Mansion Nursing And Rehab Center during CMS and state inspections, most recent first.
A Registered Nurse on an overnight shift failed to complete the medication pass and required treatments, monitoring, and documentation for most residents under her care. Record review showed that medication and treatment orders were not carried out for 40 of 48 residents reviewed during that shift, and the only drugs documented as given were Oxycodone, Ritalin, and Lorazepam, with documentation noted as inaccurate. When the missing documentation was discovered by the oncoming shift, the DON and Administrator suspected possible diversion by the agency nurse and were unable to produce evidence that residents received their ordered medications and treatments in accordance with professional standards of practice.
A resident with multiple medical conditions, including a recent fracture, sepsis, and opioid use disorder, was transferred to the hospital after a verbal altercation with staff. The facility did not provide the required written information about its bed-hold policy to the resident or their representative prior to the transfer, as confirmed by record review and staff interviews.
A resident with a history of opioid addiction and other medical conditions did not receive prescribed Methadone for two days due to the medication being unavailable. The DON reported delays in obtaining the medication from the treatment center, and the resident exhibited behavioral changes during this period. The facility could not demonstrate that the resident was kept free from significant medication errors.
The facility did not establish or document actions, measurements, or tracking systems to monitor and improve identified problem areas as required by its QAPI program. Review of records and staff interview confirmed the absence of evidence showing that performance improvement efforts were measured or tracked.
The facility did not ensure that pharmacy recommendations from monthly medication regimen reviews were reviewed or acted upon for four residents with complex psychiatric and medical conditions. Documentation and staff interviews confirmed that recommendations regarding medication changes or discontinuations, especially after incidents like falls, were not addressed as required by facility policy.
A resident with schizoaffective disorder, anxiety disorder, and PTSD did not receive recommended changes to psychiatric medications after a consultation, due to a lack of communication and follow-through among staff. The resident continued to experience increased anxiety and sleep disturbances, and the recommended medication adjustments were not implemented or reviewed by the physician.
A resident with a history of hypertensive heart disease and orthostatic hypotension was given midodrine despite physician orders to hold the medication when systolic BP exceeded 130 mm Hg. MAR review showed the medication was administered multiple times outside of these parameters, and staff interviews confirmed the failure to follow the order.
The facility did not notify or provide a final accounting of personal funds for two residents who died while receiving Medicaid benefits. Funds were still being held by the facility, and there was no evidence that the required notifications or conveyance of funds to the appropriate parties or probate jurisdiction occurred within the mandated timeframe.
Surveyors observed deficiencies in food safety standards, including a pink substance in the ice machine and an expired Hi-Cal supplement in the kitchenette. Both the LPN and Food Service Director acknowledged these issues.
The facility failed to maintain infection control by allowing an ice scoop to sit in stagnant water, risking Legionella growth. Additionally, two residents requiring Enhanced Barrier Precautions (EBP) did not receive proper care, as a Nursing Assistant was observed not wearing a gown during high-contact activities. The Director of Nursing acknowledged these lapses.
The facility failed to properly store and label medications, as observed by surveyors. An LPN acknowledged undated and improperly stored medications, including a tuberculin solution, Lorazepam tablets, and inhalers. Additionally, expired medications were found in the storage room, which the DNS confirmed should have been discarded.
Surveyors identified deficiencies in the facility's environment, including disrepair in the 2nd floor common area and resident rooms. An entertainment center had an uneven surface, and rooms had holes in drywall, chipped paint, and exposed wiring. The Operations Manager and DON acknowledged these issues.
A resident with type II diabetes mellitus experienced significant weight gain, prompting a physician's order for thyroid-related blood tests. However, the facility failed to complete the ordered lab work. A Registered Nurse acknowledged the oversight, and the DON confirmed the expectation for the lab work to be completed, highlighting a failure to meet professional standards of practice.
A resident with COPD was prescribed 2 liters of oxygen per minute, but was observed receiving higher flow rates, up to 3 liters, on multiple occasions. This discrepancy was confirmed by the DON and a nurse during a surveyor interview.
The facility failed to obtain written authorization to manage personal funds for two residents. One resident, admitted in 2011, had a balance of $4,379.42, and another, admitted in 2023, had a balance of $125.00, both without authorization. The Administrator acknowledged this oversight during an interview.
The facility did not provide quarterly financial statements to two residents who had funds held by the facility. Despite having personal needs accounts, these residents did not receive the required written accounting of their deposits, withdrawals, and balances. The Administrator confirmed the oversight during an interview.
The facility failed to notify residents receiving Medicaid benefits when their account balances approached the SSI resource limit, as required by regulations. Three residents had balances exceeding the threshold, and the Administrator could not provide evidence of written notifications.
The facility breached resident confidentiality by posting past survey results in a public area, which included identifying information of residents from previous surveys. The DON confirmed the availability of these rosters, indicating a failure to protect residents' personal and medical records.
Failure to Administer and Document Medications and Treatments During Overnight Shift
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents received treatment and care in accordance with professional standards of practice by not following provider orders for medications and treatments during a specific overnight shift. A facility-reported incident dated 1/14/2026 indicated that during the 11:00 PM to 7:00 AM shift on 1/2/2026, a Registered Nurse (Staff A) did not fulfill assigned nursing responsibilities. Record review showed that medication orders were not administered and treatment orders were not completed for 40 of 48 residents reviewed during that shift, covering the period from 11:00 PM on 1/2/2026 into 7:00 AM on 1/3/2026. Surveyor interviews with the Director of Nursing Services (DNS) and the Administrator on 1/20/2026 revealed that when the oncoming shift identified missing documentation, their initial concern was possible medication diversion by the agency nurse. The only medications documented as administered during the shift were Oxycodone, Ritalin, and Lorazepam, and the DNS and Administrator stated that the nurse’s documentation was inaccurate. They reported that when contacted, the agency nurse refused to return to the facility to complete the documentation. The DNS and Administrator were unable to provide evidence that residents received their ordered medications and treatments in accordance with professional standards of practice during the 11:00 PM to 7:00 AM timeframe in question.
Failure to Provide Bed-Hold Policy Notification Upon Hospital Transfer
Penalty
Summary
The facility failed to provide written information regarding its bed-hold policy to a resident or the resident's representative prior to the resident's transfer to a hospital. According to the facility's own Bed Hold Policy, residents and/or their representatives must be informed of the policy whenever a resident is transferred for hospitalization or therapeutic leave. However, clinical record review and staff interviews confirmed that this requirement was not met for a resident who was transferred to the hospital following a verbal altercation with staff. The resident in question had been admitted with multiple diagnoses, including an intertrochanteric fracture of the left femur with surgical repair, sepsis secondary to cellulitis of the left lower extremity, and was on daily Methadone for opioid use disorder. Despite these complex medical needs, there was no documentation in the clinical record that the resident was offered a bed-hold upon transfer. Both the DON and the Administrator confirmed during interviews that the required notification was not provided.
Failure to Administer Prescribed Methadone Due to Medication Unavailability
Penalty
Summary
A deficiency occurred when a resident admitted with multiple diagnoses, including a left femur fracture with surgical repair and sepsis secondary to cellulitis, did not receive prescribed Methadone for opioid addiction. The resident had physician orders for Methadone 40 mg in the morning and 60 mg in the evening, but the Medication Administration Record (MAR) showed that both doses were missed on two consecutive days. Documentation indicated that the medication was unavailable as the reason for the missed doses. The Director of Nursing (DON) reported that the orders for Methadone were faxed to the substance abuse treatment center after it had closed, and despite multiple calls and messages, the medication did not arrive until the resident's third day at the facility. During this period, the resident exhibited behavioral changes, including verbal aggression, which led to a behavioral health evaluation. The facility was unable to provide evidence that the resident was kept free from significant medication errors, as the resident never received the prescribed Methadone during their stay.
Failure to Measure and Track QAPI Performance
Penalty
Summary
The facility failed to implement and document effective mechanisms for monitoring and evaluating resident care as part of its Quality Assurance and Performance Improvement (QAPI) program. Record review of the facility's QAPI plan for 2024 and 2025 showed no evidence of actions, measurements, or tracking systems to ensure that efforts for improvement in identified problem areas were being made or sustained. During an interview, the Administrator was unable to provide documentation demonstrating that the facility had developed or used any actions, measurements, or tracking systems to monitor performance in these areas. This deficiency was identified through both record review and staff interview.
Failure to Act on Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that irregularities identified by the Clinical Consultant Pharmacist during monthly Medication Regimen Reviews (MRR) were acted upon for four residents. According to facility policy, recommendations from the pharmacist are to be addressed and documented by staff or the prescriber, with the prescriber either accepting and acting upon the suggestion or providing an explanation for disagreement. For each of the four residents reviewed, there was no evidence that pharmacy recommendations were reviewed or acted upon by the provider or facility staff, as required by policy. Specifically, for residents with diagnoses such as dementia, major depressive disorder, anxiety, PTSD, delusional disorder, and bipolar disorder, pharmacy recommendations regarding medication adjustments or discontinuations following incidents such as falls were not documented as reviewed or addressed. Interviews with the Director of Nursing Services confirmed the absence of documentation or evidence that these recommendations were considered or acted upon for the residents in question.
Failure to Implement Psychiatric Medication Recommendations for Resident with Mental Health Diagnoses
Penalty
Summary
A resident with diagnoses including schizoaffective disorder, anxiety disorder, and PTSD was admitted to the facility and later reported increased anxiety and sleep disturbances. The resident underwent a psychiatric consultation, which resulted in recommendations to adjust current medications and initiate a new medication to address nightmares and anxiety. The psychiatric consultation document containing these recommendations was sent to the facility, but there was no evidence that the physician was made aware of the recommendations or that the medication changes were implemented. Interviews with the resident revealed ongoing symptoms and repeated requests for medication changes, which were not addressed. Staff interviews indicated a lack of communication and follow-through regarding the psychiatric recommendations, with the responsible nurse not reviewing or acting on the recommendations and the DON acknowledging that the recommendations had not been reviewed or implemented by the physician, even eight days after the consultation. This failure resulted in the resident not receiving necessary behavioral health care and services as required.
Failure to Hold Medication per Blood Pressure Parameters
Penalty
Summary
A resident with hypertensive heart disease and orthostatic hypotension was admitted to the facility and prescribed midodrine 10 mg three times daily, with specific instructions to hold the medication if the systolic blood pressure exceeded 130 mm Hg. Review of the Medication Administration Records for June and July 2025 showed that the resident received midodrine on multiple occasions when their systolic blood pressure was above the ordered threshold, contrary to the physician's instructions. During interviews, a registered nurse confirmed that the medication was administered despite the parameters, and the Director of Nursing Services was unable to provide evidence that the medication was held as ordered.
Failure to Notify and Convey Resident Funds After Death
Penalty
Summary
The facility failed to notify the appropriate individuals or probate jurisdiction of the personal funds held for two residents who received Medicaid benefits and expired while residing at the facility. Record review showed that the facility was holding funds for both residents at the time of their deaths, but was unable to provide evidence of the amount of funds being held. Additionally, there was no documentation that the facility conveyed the residents' funds or provided a final accounting of those funds within 30 days of the residents' deaths, as required by state law. During an interview, the Administrator confirmed that the funds were still being held and that no evidence of notification or final accounting could be provided.
Deficiencies in Food Safety Standards Observed
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as observed during a survey. An inspection of the ice machine revealed an accumulation of a pink substance on the bottommost edge of the ice dispenser shield, which was easily removable with a paper towel. This observation was confirmed by a Licensed Practical Nurse, who acknowledged the presence of the substance. Additionally, the Food Service Director also confirmed the accumulation of the pink substance within the ice machine. Further inspection of the kitchenette revealed an opened bottle of Hi-Cal oral supplement dated 5/7/2024, which was approximately three-quarters full. According to the product information guide, once opened, the supplement should be labeled with the time and date, refrigerated, covered, and used within 48 hours. The LPN acknowledged that the Hi-Cal supplement was past its use-by date and should have been discarded. The Food Service Director also confirmed that the Hi-Cal supplement should have been discarded.
Infection Control and EBP Failures
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by surveyor observations and staff interviews. During an inspection of the nourishment area, an ice scoop was found submerged in approximately 2 inches of stagnant water in its designated container. This was acknowledged by both a Licensed Practical Nurse and the Food Service Director, who confirmed that the ice scoop should not be in standing water. This oversight in water management could potentially lead to the growth of Legionella and other waterborne pathogens, posing a risk to the residents and staff. Additionally, the facility did not adhere to Enhanced Barrier Precautions (EBP) for two residents. Resident ID #20, who was readmitted with dementia and a wound on the right great toe, had signage indicating the need for gown and glove use during high-contact activities. However, a Nursing Assistant was observed changing the resident's linens without wearing a gown. Similarly, Resident ID #26, with a diagnosis of schizoaffective disorder, required EBP during personal hygiene and toileting assistance. The same Nursing Assistant was observed not wearing a gown while providing these services. The Director of Nursing Services acknowledged the failure to follow EBP protocols for these residents.
Deficiencies in Medication Storage and Labeling
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with accepted professional principles, as observed during a survey. In the medication refrigerator, a bottle of tuberculin purified protein derivative solution was found opened and undated, which was acknowledged by the LPN present. Additionally, a medication cart contained a packet of Lorazepam tablets with a discontinue date that had passed, and the LPN confirmed that the medication should have been removed. Furthermore, two inhalers on another medication cart were opened and undated, contrary to manufacturer instructions, which was also acknowledged by the LPN. In the medication storage room, several expired medications were found, including bottles of Vitamin E, Mucus relief tablets, and Fish oil capsules. The Director of Nursing Services acknowledged that these medications were expired and should have been discarded. During a follow-up interview, the DNS could not provide evidence that the medications were stored appropriately as required.
Facility Environment Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, and comfortable environment for residents, staff, and the public, as observed by surveyors on three of six units. On the 2nd floor common area, an entertainment center was found with scattered chip marks and pieces of wood lifting, creating an uneven surface. The Operations Manager acknowledged the disrepair. In a resident room on the [NAME] 1 Unit, three holes in the drywall and chipped paint over the resident's bed were observed. In another room on the Annex 1 Unit, exposed wiring from a call light system box and chipped paint behind the resident's bed and recliner were noted. The Director of Nursing Services acknowledged these findings and indicated the need for repairs.
Failure to Follow Physician's Order for Bloodwork
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice by not following a physician's order for a resident with significant weight gain. The resident, who was admitted with a diagnosis including type II diabetes mellitus, had a Minimum Data Set assessment indicating intact cognition. A Registered Dietician recommended bloodwork to check the resident's thyroid panel due to continued significant weight gain. A physician's order was issued for specific thyroid-related blood tests, including T-3 total, T-3 Uptake, and TSH, to diagnose potential thyroid conditions. However, a review of the records did not reveal any evidence that the ordered lab work was completed. During interviews, a Registered Nurse acknowledged that the physician's order was not followed, and the lab work was not conducted as ordered. The Director of Nursing Services also confirmed that she would have expected the lab work to be completed according to the physician's order, indicating a lapse in following professional standards of practice within the facility.
Failure to Adhere to Oxygen Administration Orders
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident with Chronic Obstructive Pulmonary Disease (COPD). The resident was readmitted to the facility with a physician's order to receive oxygen at 2 liters per minute via a nasal cannula every shift. However, surveyor observations revealed that the resident was receiving oxygen at higher flow rates than prescribed. On multiple occasions, the resident was observed receiving 3 liters of oxygen, and on one occasion, 2.5 liters. During an observation in the presence of the Director of Nursing Services and a Registered Nurse, it was confirmed that the resident was receiving 3 liters of oxygen instead of the ordered 2 liters. Both the Director of Nursing Services and the Registered Nurse acknowledged this discrepancy during a surveyor interview.
Failure to Obtain Written Authorization for Managing Residents' Funds
Penalty
Summary
The facility failed to obtain written authorization to manage personal funds for two residents. Resident ID #10, admitted in September 2011, had a personal needs account balance of $4,379.42 as of June 10, 2024, without having authorized the facility to hold these funds, as indicated by the absence of an authorization document dated September 9, 2011. Similarly, Resident ID #38, admitted in November 2023, had a personal needs account balance of $125.00 as of May 14, 2024, without providing written authorization for the facility to manage their funds, as shown by the lack of an authorization document dated November 7, 2023. During an interview on July 5, 2024, the Administrator acknowledged the absence of written authorization for holding the funds of these two residents. This oversight indicates a failure in the facility's process for managing residents' financial affairs, as required by regulations.
Failure to Provide Quarterly Financial Statements to Residents
Penalty
Summary
The facility failed to provide a written accounting of deposits, withdrawals, and balances at least quarterly for two residents. Resident ID #3, admitted in May 2023, had funds held by the facility, but there was no evidence of quarterly statements being completed and provided. Similarly, Resident ID #38, admitted in November 2023, also had funds held by the facility without any quarterly statements being issued. During an interview, the Administrator acknowledged that these residents had not received the required written accounting of their personal funds as per the regulation.
Failure to Notify Residents of Medicaid Eligibility Risk
Penalty
Summary
The facility failed to notify residents or their representatives who receive Medicaid benefits when their account balances reached $200 less than the Social Security Income (SSI) resource limit. This deficiency was identified for three residents whose personal needs funds were managed by the facility. Specifically, Resident ID #10 had a balance of $4,370.42, Resident ID #16 had a balance of $4,549.22, and Resident ID #17 had a balance of $4,186.66. According to Title 210-Executive Office of Health and Human Services, Chapter 50-Medicaid Long-Term Services and Supports (LTSS), the facility is required to notify residents in writing when their balance approaches the SSI Medicaid eligibility resource limit of $4,000. During an interview, the Administrator was unable to provide evidence that these notifications were made, resulting in a failure to comply with the regulatory requirement.
Breach of Resident Confidentiality in Survey Results Posting
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical records, as evidenced by the posting of past survey results in a public area. During a surveyor observation in the main hallway, a Survey Results envelope was found containing copies of previous survey rosters with identifying information of residents. These rosters included resident IDs from surveys conducted on various dates, specifically 10/4/2019, 4/15/2021, 6/16/2022, and 7/21/2023. The Director of Nursing Services confirmed that these resident rosters were accessible with the Survey Results, indicating a breach of privacy and confidentiality for the residents involved.
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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