Overlook Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pascoag, Rhode Island.
- Location
- 14 Rock Avenue, Pascoag, Rhode Island 02859
- CMS Provider Number
- 415045
- Inspections on file
- 19
- Latest survey
- May 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Overlook Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions sustained a second-degree burn after spilling hot chocolate prepared with excessively hot water from a Keurig machine. Staff had not received training on safe temperatures for serving hot beverages, and the water temperature was measured at 180.3°F, above recommended safety guidelines. The administrator and staff educator confirmed that no education on this topic had been provided.
Surveyors found that food items in the main kitchen and two kitchenettes were not labeled or dated according to professional standards and facility policy, including fried chicken, chicken patties, hamburger patties, pancakes, and resident food brought from outside. Additionally, an oven was found with burnt residue and lacked a cleaning schedule. The FSD and Administrator acknowledged these deficiencies during interviews.
The facility did not ensure that antibiotic orders for three residents included the required indication for use, as outlined by CDC guidelines and facility policy. Additionally, the facility lacked an active Antibiotic Stewardship Team, despite policy requirements for regular meetings and program analysis.
Three residents' medical records lacked documentation showing whether they received, declined, or had a contraindication to the recommended pneumococcal vaccines, despite completion of initial vaccine series. The DON confirmed that this documentation was missing and only became aware of the issue after it was identified by a surveyor.
A resident was started on amlodipine for hypertension without being informed, and neither the resident nor their representative was notified about the medication, its risks, or alternatives. The omission was confirmed through record review and interviews with the resident, their representative, nursing staff, and the DON.
Two residents with significant medical conditions sustained skin tears of unknown origin, and the facility did not conduct or document investigations into the causes of these injuries. Both the DON and an LPN confirmed that no investigation was initiated or recorded, despite facility policy requiring such action.
The facility did not complete required AIMS assessments for a resident on psychotropic medications and failed to ensure timely hemoglobin A1C monitoring for a resident receiving insulin, as ordered by providers. These omissions were confirmed by the DON and relevant clinical staff.
Two residents did not receive care in accordance with physician orders: one resident with Parkinson's disease and a history of falls was not reported to the provider after a significant change in orthostatic blood pressure, and another resident with spinal stenosis and neurogenic bladder did not have required urology and MRI appointments scheduled. Staff interviews confirmed these omissions, indicating a failure to follow professional standards and physician directives.
A resident with stage 4 pressure ulcers received wound care from an RN who failed to use an applicator to pack the wounds and did not change gloves between treating two separate wounds. The DON confirmed these actions did not meet professional standards of practice, and there was no evidence that wound care was provided in a manner consistent with promoting healing and preventing infection.
Surveyors found that the facility did not have required physician orders specifying catheter size, balloon size, or diagnosis for two residents with urinary catheters, as mandated by facility policy. Additionally, there was no evidence that a trial void was attempted for a resident as ordered by a physician. The DON and an LPN confirmed the lack of required documentation.
A resident with COPD and respiratory failure was not provided oxygen therapy at the prescribed rate of 2 LPM, as surveyors observed the oxygen being administered at approximately 3.5 LPM on several occasions. Staff confirmed the discrepancy between the physician's order and the care provided.
A resident being treated for a UTI was prescribed Bactrim for 7 days, totaling 14 doses, but received 17 doses instead. The DON confirmed that the resident should have only received the prescribed amount.
The facility did not accurately maintain medical records for two residents: one was documented as receiving oxygen at the prescribed rate, but was observed receiving a higher rate, and another had AIMS assessments documented as completed when there was no evidence they were actually performed. Staff interviews confirmed the discrepancies in documentation.
A resident with severe dementia and a history of falls was manually assisted to a standing position by two staff members after an unwitnessed fall, despite exhibiting severe pain and being unable to stand independently. Facility protocol required the use of a Hoyer lift in such situations, but staff did not follow this procedure, and the resident was later diagnosed with a right hip fracture. Staff interviews revealed a lack of awareness of the protocol.
The facility failed to follow physician's orders for two residents. A resident with a physician's order for waffle boots was found without them, and the boots were documented as unavailable multiple times. Another resident had an incomplete order for Nystatin powder, which did not specify the affected area, yet the treatment was administered. The DON acknowledged the incomplete order.
The facility failed to ensure consistency between residents' advance directives and their EMR. A resident had conflicting code status documentation, while another lacked current advance directive evidence. Two residents had unsigned MOLST forms with discrepancies between the MOLST and EMR. Staff were instructed to refer to paper documents, but inconsistencies persisted.
A resident with a known allergy to blueberries was mistakenly served a breakfast tray containing blueberry coffeecake, intended for another resident. The error was confirmed through staff interviews, including a CMT, Cook, and Nursing Assistant, who acknowledged the mistake. The DON confirmed the resident's allergy and the error in serving the incorrect tray.
Resident Burned by Hot Beverage Due to Lack of Staff Training and Unsafe Temperatures
Penalty
Summary
A deficiency occurred when a resident with chronic kidney disease, dependence on renal dialysis, and diabetes, who was cognitively intact, sustained a second-degree burn after spilling hot chocolate on their thigh. The hot chocolate was prepared by a nursing assistant using a Keurig coffee maker in the facility's kitchenette. The incident resulted in a burn measuring 7 by 12 centimeters and 0.1 centimeters deep, with 30% scabbing and involvement of both the dermis and epithelial layers of the skin. The resident reported significant pain from the burn. Investigation revealed that the water dispensed from the Keurig machine reached a temperature of 180.3°F, which exceeds the recommended safe serving range of 130 to 160°F for hot beverages. Staff interviews indicated that nursing assistants had not received education on safe temperatures for reheating or serving food and beverages, and the staff educator confirmed that such training was not provided to any staff members. The administrator acknowledged awareness of the incident and the lack of staff education regarding the risks associated with hot liquids.
Failure to Properly Label, Date, and Store Food Items in Kitchen and Kitchenettes
Penalty
Summary
Surveyor observations, record reviews, and staff interviews revealed that the facility failed to store and distribute food in accordance with professional standards for food service safety in both the main kitchen and two kitchenettes. Specifically, multiple food items in the main kitchen freezer, such as fried chicken, chicken patties, hamburger patties, pancakes, and shaved beef, were found without labels or discard dates as required by the Rhode Island Food Code. The Food Service Director (FSD) acknowledged that these items were not labeled or dated per regulations. Additionally, the facility policy requires food brought in by visitors to be labeled with the resident's name and date, and to discard perishable items older than three days, but items in the 1st floor kitchenette were only labeled with resident names and lacked discard dates. Further deficiencies were observed in the 2nd floor kitchenette, where a large bag of tacos and a container of an unidentified food substance were found without labels or discard dates. The oven in this kitchenette also contained residual burnt matter, and the FSD was unable to provide a cleaning schedule for the oven. Both the FSD and the Administrator confirmed during interviews that it was their expectation for all food items to be properly labeled, dated, or discarded according to regulations and facility policy.
Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish and maintain an effective Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use. Specifically, for three residents reviewed for antibiotic use, physician orders for antibiotics did not include the required indication for use, as mandated by both CDC guidelines and the facility's own policy. The residents involved had diagnoses such as acute bronchiolitis due to respiratory syncytial virus, aftercare following surgical amputation, and pneumonia. In each case, the physician's orders for antibiotics lacked documentation of the clinical indication, which was confirmed during interviews with the Director of Nursing Services (DNS), who acknowledged the omission. Additionally, the facility did not have an active Antibiotic Stewardship Team as required by its policy. The policy specified that such a team should meet regularly, maintain meeting minutes, and analyze the efficacy of the program annually. However, during interviews, the DNS confirmed that the facility did not have an antibiotic stewardship team in place, nor were there any meeting minutes available, despite the policy's requirements.
Failure to Document Pneumococcal Vaccination Status
Penalty
Summary
The facility failed to ensure that the medical records of three residents included documentation indicating whether the residents received the pneumococcal vaccination, or if not, whether it was declined or medically contraindicated. Specifically, for three residents admitted between 2018 and 2019, record reviews showed that while initial pneumococcal vaccine series (PCV13 and PPSV23) were completed, there was no evidence that the newer recommended vaccines (PCV20 or PCV21) were offered, administered, or declined. In one case, a resident consented to a pneumococcal vaccination, but there was no documentation that the vaccine was actually given or refused. During an interview, the DON confirmed that the facility had not documented whether these residents received or declined the updated pneumococcal vaccines, and was unable to provide such evidence until prompted by the surveyor. The lack of documentation was only identified after the surveyor brought the issue to the facility's attention.
Failure to Inform Resident and Representative of New Antihypertensive Medication
Penalty
Summary
A resident with a diagnosis including hypertension was admitted to the facility and subsequently prescribed amlodipine 5 mg daily for blood pressure control. Documentation in the resident's medical record, including progress notes and physician orders, confirmed the initiation and administration of amlodipine. However, there was no evidence that the resident or the resident's representative was informed in advance about the addition of amlodipine, its associated risks and benefits, or alternative treatment options prior to the medication being prescribed and administered. The manufacturer's insert for amlodipine lists several potential side effects, including headache, swelling, dizziness, and a potential risk of heart attack when first taking the medication. The deficiency was further substantiated by interviews with the resident, the resident's representative, and facility staff. The resident's family member, who serves as the emergency contact, expressed concern about the resident experiencing dizziness and was unaware of the new medication. Both the resident and the representative confirmed they had not been informed about the addition of amlodipine. Staff interviews revealed that the nurse responsible for administering the medication did not notify the resident or representative, and the Director of Nursing Services acknowledged that such notification was expected prior to starting the treatment.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure that injuries of unknown origin were thoroughly investigated for two residents who sustained skin tears. For one resident with Alzheimer's Disease, documentation showed the presence of two new skin tears on the left upper extremity, with the resident unable to explain their origin. Record review did not reveal any evidence that an investigation was conducted to determine how these injuries occurred. During an interview, the Director of Nursing Services (DNS) acknowledged the lack of an investigation and confirmed that one should have been initiated. Similarly, another resident with chronic kidney disease sustained a 1-centimeter skin tear to the left knee, with the progress note lacking any explanation for the injury's origin. Further review of records did not show that an investigation was conducted to determine the cause of the skin tear. Interviews with both a Licensed Practical Nurse and the DNS confirmed that the documentation did not include the origin of the injury and that no investigation had been performed.
Failure to Complete Required Assessments and Lab Monitoring
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for two residents. For one resident with a history of anxiety, bipolar disorder, PTSD, and panic disorder, the care plan required regular Abnormal Involuntary Movement Scale (AIMS) assessments due to psychotropic medication use. A physician's order specified that AIMS assessments should be completed quarterly in March, June, September, and December. However, records showed that the last AIMS assessment was completed in August 2024, with no evidence of assessments being performed on the subsequent required dates. Both the resident's Nurse Practitioner and the Director of Nursing Services confirmed that the assessments had not been completed as ordered. For another resident with diabetes mellitus and hyperglycemia, the care plan identified risks related to diabetes and insulin administration. The resident was prescribed daily Semglee (insulin glargine-yfgn), and a provider's note indicated that a hemoglobin A1C test should be repeated in three months following a previous test. However, there was no evidence that the follow-up hemoglobin A1C was completed as ordered. The Director of Nursing Services acknowledged that the last A1C test was in November 2024 and could not provide documentation of a repeat test until after the issue was identified by the surveyor.
Failure to Follow Physician Orders for Orthostatic Blood Pressure and Medical Appointments
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by not following physician's orders for two residents. For one resident with Parkinson's disease, a history of falls, and on antipsychotic medication, the physician had ordered orthostatic vital signs to be taken every three months. The resident experienced multiple episodes of dizziness and falls, and a quarterly assessment revealed a significant drop in orthostatic blood pressure. However, there was no evidence that the provider was notified of this change, despite staff and the nurse practitioner stating that such changes should be reported. For another resident with spinal stenosis and neurogenic bladder dysfunction, the physician ordered a urology consult for possible suprapubic tube placement and an MRI of the spine. The resident expressed interest in the procedure, and the physician documented the need to schedule the appointments. Despite this, there was no evidence that either the urology or MRI appointments had been scheduled. Staff interviews confirmed that the appointment scheduler was unaware of the orders, and the LPN stated that no appointments had been made. In both cases, the facility did not follow through on physician's orders, either by failing to notify the provider of significant clinical changes or by not scheduling required medical appointments. These actions resulted in a failure to provide appropriate treatment and care according to the residents' needs and physician directives.
Failure to Follow Professional Standards During Pressure Ulcer Care
Penalty
Summary
A resident admitted with spinal stenosis and stage 4 pressure ulcers to the coccyx and right gluteal fold was observed to receive wound care that did not follow professional standards of practice. Physician orders specified the use of vashe soak, collagen with silver, calcium alginate, kerlix, and super absorbent dressings for the coccyx wound, and vashe soak, collagen powder, calcium alginate, and silicone super absorbent dressing for the right gluteal fold wound. During wound care, the RN applied collagen powder on top of calcium alginate and packed the coccyx wound with her gloved fingers, followed by packing kerlix into the wound, also with her fingers, instead of using an applicator as required. Immediately after treating the coccyx wound, the RN proceeded to treat the right gluteal fold wound without changing gloves, again using her fingers to apply and pack the wound dressing. The RN acknowledged during interview that she did not use an applicator and did not change gloves between wound treatments. The DON also confirmed that the RN should have used an applicator and changed gloves between wounds, and was unable to provide evidence that wound care was provided in accordance with professional standards to promote healing and prevent infection for the resident.
Failure to Ensure Proper Catheter Orders and Documentation
Penalty
Summary
Surveyor observations, record reviews, and staff interviews revealed that the facility failed to provide appropriate treatment and services for residents with urinary catheters. For one resident with a foley catheter, there was no physician order on file specifying the catheter size, balloon size, or diagnosis to support its use, despite facility policy requiring this documentation. Both the LPN and the Director of Nursing Services (DNS) confirmed the absence of the required order. Similarly, another resident with a suprapubic catheter did not have an order specifying the catheter size, balloon size, or diagnosis, as required by policy, which was also acknowledged by the DNS. Additionally, a third resident with a foley catheter had a physician order for a trial void following a urologist's recommendation, but there was no evidence in the records that the trial void was attempted or failed as ordered. The DNS was unable to provide documentation to show that the trial void had been carried out. These findings indicate lapses in following facility policy and physician orders regarding catheter care and documentation.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD) and acute and chronic respiratory failure with hypercapnia was not provided respiratory care consistent with professional standards. The resident was readmitted to the facility with a care plan and physician's order specifying oxygen therapy at 2 liters per minute (LPM). However, surveyor observations on multiple occasions revealed that the resident was receiving oxygen at approximately 3.5 LPM, which was not in accordance with the prescribed order. Staff interviews confirmed the discrepancy, with a registered nurse acknowledging that the resident was not receiving the ordered amount of oxygen. The Director of Nursing Services also indicated that the expectation was for the resident to receive oxygen at the ordered rate. Laboratory results showed the resident had elevated carbon dioxide levels, which can be associated with both COPD and supplemental oxygen use. The failure to administer oxygen as ordered constituted a lack of adherence to professional standards of respiratory care.
Resident Received More Antibiotic Doses Than Prescribed
Penalty
Summary
A resident with a diagnosis including urinary tract infection (UTI) was readmitted to the facility in February 2024. Medical records show that the provider prescribed Bactrim 800-160 mg to be administered twice daily for 7 days, totaling 14 doses. However, review of the March 2025 Medication Administration Record revealed that the resident received 17 doses of Bactrim between 3/12 and 3/20, which is 3 doses more than what was ordered by the provider. During an interview, the Director of Nursing Services confirmed that only 14 doses should have been administered as prescribed.
Failure to Accurately Maintain Medical Records for Oxygen Administration and AIMS Assessments
Penalty
Summary
The facility failed to accurately maintain medical records in accordance with accepted professional standards for two residents. For one resident with chronic obstructive pulmonary disease (COPD), the care plan and physician's order specified oxygen at 2 liters per minute (LPM). However, surveyor observations on multiple occasions found the resident receiving approximately 3.5 LPM of oxygen, while the Medication Administration Records (MARs) inaccurately documented administration at 2 LPM. A registered nurse also documented the ordered rate despite observing a different rate earlier in the day and could not explain the discrepancy during an interview. For another resident with a history of anxiety, bipolar disorder, PTSD, and panic disorder, the care plan required regular Abnormal Involuntary Movement Scale (AIMS) assessments as directed by a physician's order. Although records indicated that AIMS assessments were completed on specific dates, further review revealed that the last actual assessment was completed prior to those dates, and there was no evidence to support the documented completion of the assessments. The Director of Nursing Services was unable to provide accurate records for these assessments during the surveyor interview.
Failure to Follow Fall Protocol and Professional Standards During Post-Fall Transfer
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality in relation to the post-fall transfer of a resident with severe dementia, muscle weakness, and a history of numerous falls. According to the facility's fall protocol, if a resident is unable to get up independently after a fall, staff are required to use a Hoyer lift with two staff members to assist the resident back into bed. However, after an unwitnessed fall, the resident was found on the floor, exhibiting severe pain and guarding of the right leg. Despite these symptoms and the resident's inability to stand without assistance, two staff members manually assisted the resident to a standing position from the floor, rather than utilizing the Hoyer lift as required by protocol. Further review revealed that the resident was subsequently diagnosed with a right hip fracture following the incident, which was confirmed by a portable x-ray and hospital emergency room evaluation. Staff interviews indicated a lack of awareness of the facility's fall protocol, and the Assistant Director of Nursing Services confirmed that the expectation was for staff to use a Hoyer lift in such situations. The failure to follow established protocol and professional standards of care directly contributed to the deficiency cited in the report.
Failure to Follow Physician's Orders for Resident Care
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice by not following physician's orders for two residents. Resident ID #60, who was admitted with diagnoses including weakness and the need for assistance with personal care, had a physician's order for bilateral waffle boots to be applied as tolerated. However, during a surveyor observation, the resident was found without the waffle boots, and staff were unable to locate them. The Treatment Administration Record indicated that the waffle boots were documented as unavailable for 18 out of 39 opportunities, and the Director of Nursing Services could not explain the discrepancy, although the boots were later found in the laundry room. For Resident ID #3, who was admitted with cerebral infarction and diabetes mellitus, there was a physician's order for Nystatin powder to be applied to a fungal rash twice daily. However, the order did not specify the affected area for treatment. Despite this, the treatment was signed off as administered in the Treatment Administration Records for May and June. During an interview, an LPN revealed that she applied the powder to the reddened areas under the resident's chest folds, which was not specified in the order. The Director of Nursing Services acknowledged that the order was incomplete and should have indicated the affected area for the treatment.
Inconsistencies in Advance Directives and EMR
Penalty
Summary
The facility failed to ensure that residents' advance directives were consistent with their electronic medical records (EMR) for several residents. For Resident ID #2, there was a discrepancy between the MOLST indicating Full Code and a physician's order indicating DNR, with the EMR banner also showing DNR. Staff were unable to confirm the resident's true code status. Resident ID #3 lacked evidence of an advance directive or code status upon readmission, despite having a previous DNR directive. Staff treated the resident as Full Code due to the absence of current documentation. For Resident ID #68, the MOLST was unsigned by the healthcare provider and indicated DNR/DNI, but the EMR only showed DNR. Similarly, Resident ID #398 had an unsigned MOLST indicating DNR and Comfort Measures Only, but the EMR showed DNR/DNI. The Director of Nursing Services acknowledged the inconsistencies and the lack of updated advance directives upon re-admission for some residents. Staff were instructed to refer to paper documents for code status, but inconsistencies between MOLST documents, orders, and EMR banners were evident.
Failure to Accommodate Resident Allergy
Penalty
Summary
The facility failed to provide food that accommodates resident allergies, specifically for a resident with a known allergy to blueberries. The resident, who was readmitted to the facility with diagnoses including dementia and anxiety, was mistakenly given a breakfast tray intended for another resident. This tray contained blueberry coffeecake, which the resident consumed. The error was identified during a surveyor observation, and staff interviews confirmed the mistake. A Certified Medication Technician acknowledged the error, and the Cook confirmed that the meal ticket listed blueberry coffeecake, which was served to the resident. The Nursing Assistant admitted to serving the incorrect tray, and the Director of Nursing Services confirmed the resident's allergy and acknowledged the mistake.
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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