Riverview Healthcare Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Coventry, Rhode Island.
- Location
- 546 Main Street, Coventry, Rhode Island 02816
- CMS Provider Number
- 415082
- Inspections on file
- 37
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at Riverview Healthcare Community during CMS and state inspections, most recent first.
The facility did not provide enough nursing staff during an overnight shift, leaving only one NA and one nurse to care for 24 residents on a unit. Two residents with significant care needs, including frequent falls, incontinence, and pressure ulcers, did not receive the required level of care and monitoring. Staff and management interviews confirmed that the staffing was below the facility's own minimum requirements and was insufficient to meet residents' needs.
A resident experiencing severe respiratory distress was emergently transferred to a hospital with another resident's identifiers and medical record due to an LPN's error. The resident received care under the wrong identity for several hours, and the hospital contacted the wrong representative for consent for intubation. The DON confirmed the error and the resident's history of respiratory compromise.
The facility did not ensure consistent and comprehensive care plans for two residents with complex transfer and fall prevention needs. Documentation across care plans, Kardex, physician orders, SPH evaluations, and NA assignments contained conflicting information about required transfer assistance, leading to confusion among staff. Interviews with LPNs, NAs, and the DON confirmed that transfer instructions were not consistently communicated or documented.
A resident with multiple chronic conditions experienced a significant change in condition and was transferred to the hospital, but the facility failed to notify the correct physician and the resident's representative. Instead, an LPN contacted the provider for a different resident and did not inform the appropriate parties, resulting in incorrect documentation and confusion for the resident's family.
A resident with severe respiratory and cardiac conditions was transferred to the hospital with another resident's medical record and identifiers after an LPN misidentified the patient and failed to follow protocol for reporting a change in condition. The hospital treated the resident under the wrong information for several hours, and the DON could not provide evidence of the LPN's competency with acute condition protocols.
The facility failed to maintain safe water temperatures, with readings exceeding the maximum allowable limit on all floors. A resident reported the water was hot enough to cause skin reddening, confirmed by surveyors. Despite recorded temperatures exceeding limits, no corrective action was documented, and the facility could not provide evidence of ensuring a hazard-free environment.
The facility was cited for deficiencies in food safety standards. Two staff members in the main kitchen were observed without beard restraints while handling food, violating the Rhode Island Food Code. Additionally, an ice machine lacked the required air gap, as confirmed by the Director of Maintenance and the Food Service Director.
The facility failed to ensure a functioning call light communication system, leading to long wait times for residents needing assistance. Staff interviews and observations revealed that call lights did not alert staff directly or through a centralized system, as walkie talkies were no longer in use.
The facility failed to follow physician orders and care plans for several residents, including improper wound care, lack of documentation for glucose monitoring, and incorrect application of therapeutic devices. Observations revealed non-compliance with prescribed treatments, such as wound dressing changes, hand splint usage, and hot pack application, highlighting deficiencies in adhering to professional standards of practice.
The facility failed to implement contact precautions for residents with MDROs, as staff members entered rooms without wearing gowns and gloves despite clear signage. Residents with MRSA and ESBL were affected, and staff interviews revealed misunderstandings about precaution requirements. The Infection Preventionist and facility leadership confirmed the expectation for staff to follow these precautions.
A facility failed to provide a resident with a smoking apron as required by their care plan, leading to cigarette ashes landing on their clothing. Despite the care plan indicating the need for a smoking apron, staff were unaware of when it should be applied, and there was no documentation of the resident's refusal to use it.
The facility failed to prevent significant medication errors involving Coumadin administration for multiple residents. Errors included incorrect transcription of orders, missed doses, and incorrect dosing, leading to elevated INR levels and potential health risks. Staff acknowledged these errors during surveyor interviews.
A resident with a Stage 2 pressure injury developed a new Stage 1 pressure injury on the right heel. Despite identification by an LPN, there was no evidence of provider notification or treatment implementation. Weekly skin checks noted the injury, but no further description or treatment orders were documented. The DON was unaware of the injury, leading to a deficiency in pressure ulcer care and prevention.
A resident with a history of traumatic brain injury and anxiety, diagnosed with Influenza A, did not receive appropriate oxygen therapy due to an incorrectly transcribed physician's order. The resident experienced a fall and distress with fluctuating oxygen saturation levels, leading to a hospital transfer and diagnosis of acute respiratory failure and pyothorax. Staff interviews revealed a lack of awareness of the resident's oxygen needs and the transcription error.
A resident's medical record was inaccurately documented, indicating an open area on the coccyx that did not exist. This error was acknowledged by the RN who completed the assessment, and the DON confirmed the inaccuracy but could not explain it. The deficiency was identified during a surveyor interview and record review.
A resident with congestive heart failure, type 2 diabetes, and major depressive disorder had a physician's order for daily weights, but the facility failed to obtain the resident's weight on multiple occasions and did not report a significant weight gain to the provider. The resident denied refusing to be weighed, and the primary nurse admitted to documenting refusals when the resident was asleep. The Nurse Practitioner was unaware of the weight gain, indicating a communication breakdown within the facility.
Insufficient Overnight Staffing Resulting in Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff on the One East Unit during the overnight shift, resulting in only one nursing assistant (NA) and one nurse being present to care for 24 residents. This staffing level was below the facility's own minimum requirement of one nurse and two NAs for the unit. Staff interviews confirmed that management was aware of the unsafe staffing situation, and the Assistant Director of Nursing Services acknowledged that staffing with less than two NAs would not be safe, especially for residents requiring lifts for transfers. Record review showed that only nine NAs worked in the facility that night, which was below the required minimum for all units combined. Two residents on the unit were directly affected by the staffing shortage. One resident, admitted with dementia, lack of coordination, and a history of falls, required maximum assistance with toileting, hygiene, and transfers using a mechanical lift, as well as frequent checks to prevent skin breakdown. This resident experienced multiple falls during their admission. Another resident, admitted with a history of stroke and schizoaffective disorder, was incontinent, required maximum assistance with hygiene, had impaired mobility, and had a stage two pressure ulcer requiring repositioning at least every two hours. This resident also experienced multiple falls and required 15-minute safety checks. Staff interviews indicated that the single NA on duty was unable to complete more than one round of care for each resident due to insufficient staffing.
Failure to Provide Accurate Resident Identification During Emergency Transfer
Penalty
Summary
The facility failed to ensure accurate and appropriate information was communicated to the receiving health care provider during an emergent discharge. When a resident experienced a significant change in condition requiring emergency transfer to an acute care facility, an LPN incorrectly identified the resident and sent the individual to the hospital with another resident's identifiers and medical record. As a result, the resident was registered at the hospital under the wrong name and date of birth, and medical care was provided under the incorrect identity for approximately two hours. The error was discovered when the hospital contacted the facility to clarify the resident's identity. Record review showed that the resident who was actually transferred had a history of chronic obstructive pulmonary disease and congestive heart failure and was in severe respiratory distress at the time of transfer, requiring intubation. The incorrect medical record and identifiers were provided to EMS, and the resident was unable to correct the information due to decreased consciousness. The Director of Nursing Services confirmed that the wrong medical record was sent and acknowledged the resident's history of respiratory compromise. The incident resulted in the resident's representative not being contacted for consent for intubation, as the hospital had contacted the wrong representative based on the incorrect identifiers.
Failure to Implement Consistent, Comprehensive Care Plans for Safe Transfers
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for two residents with identified needs for safe transferring and fall prevention. For one resident with type II diabetes and chronic kidney disease, there were multiple conflicting interventions documented regarding transfer assistance, including discrepancies between the care plan, Kardex, physician orders, Safe Patient Handling (SPH) evaluations, and nursing assistant (NA) assignments. These inconsistencies ranged from requiring a mechanical lift with two staff, to a stand and pivot transfer with a gait belt, to a one-person assist, with no evidence of consistent communication or documentation to ensure safe transfers. Staff interviews confirmed the lack of alignment and clarity in transfer instructions across different documentation sources. For another resident with type II diabetes and muscle weakness, similar inconsistencies were found. The care plan, Kardex, physician orders, SPH evaluation, and NA assignments all contained differing information regarding the resident's transfer and ambulation needs, ranging from supervision with a walker to requiring a mechanical lift with two staff. Staff interviews acknowledged that the SPH status was not consistently reflected across all forms of communication and documentation, and that the information should be uniform to ensure safe care. These findings were based on record reviews, staff interviews, and a community complaint alleging frequent patient falls and safety risks.
Failure to Notify Physician and Representative of Resident Change in Condition
Penalty
Summary
The facility failed to immediately notify the appropriate physician and the resident's representative when a resident experienced a significant change in condition and required emergency transfer to the hospital. Specifically, a resident with chronic obstructive pulmonary disease and congestive heart failure was found to have altered mental status, shortness of breath, excessive sputum, and was unable to follow commands. Emergency Medical Services were called, and the resident was transferred to the hospital, where they required intensive care and intubation. However, the facility contacted the on-call provider for a different resident and did not notify the correct physician or the resident's representative about the change in condition or the hospital transfer. Record review and staff interviews confirmed that the progress notes and physician orders were incorrectly documented for another resident, not the one who was actually experiencing the emergency. The resident's representative was not informed of the transfer, and the hospital was given incorrect patient identifiers. The Director of Nursing and the Administrator were unable to provide evidence that the correct notifications were made as required. The deficiency was identified through review of records, interviews with staff and resident representatives, and cross-referenced with related deficiencies.
Failure to Ensure Nursing Staff Competency During Emergency Transfer
Penalty
Summary
Licensed nursing staff failed to demonstrate the necessary competencies and skills to meet resident needs during an emergency transfer. Specifically, an LPN incorrectly identified a resident experiencing a significant change in condition and reported the wrong resident to the on-call provider. The LPN also sent the incorrect medical record and patient identifiers with the resident during transfer to the hospital, resulting in the hospital treating the resident under another individual's information for approximately two hours. The facility's policy required nursing staff to collect and organize pertinent information and accurately report the resident's current symptoms and status to the physician, which was not followed in this instance. The resident involved had a history of chronic obstructive pulmonary disease and congestive heart failure and was admitted to the hospital's Intensive Care Unit requiring intubation after presenting with altered mental status, excessive sputum, and cool skin. The LPN did not provide a verbal report to the hospital at the time of transfer, and the Director of Nursing Services was unable to provide evidence that the LPN was competent with the facility's protocol for acute condition changes. This series of actions and omissions resulted in the resident being at risk for delayed or inappropriate treatment.
Unsafe Water Temperatures in Facility
Penalty
Summary
The facility failed to maintain safe water temperatures, resulting in an environment that was not free from accident hazards. During a survey, it was observed that water temperatures on all three floors of the facility exceeded the maximum allowable limit of 118 degrees Fahrenheit, as per state regulations. Specific instances included water temperatures reaching up to 125.1 degrees Fahrenheit, which was confirmed through both resident interviews and direct measurement by surveyors. A resident reported that the water was hot enough to cause reddening of the skin, and this was corroborated by the surveyor's observation. The facility's records indicated that water temperatures had been recorded as exceeding 120 degrees Fahrenheit on multiple occasions, yet there was no evidence that these findings were reported or corrected according to the facility's policy. The Regional Maintenance Director acknowledged the issue, attributing it to a potential problem with the mixing valve, but no corrective action was documented. The Administrator and Director of Nursing Services were unable to provide evidence that the facility had taken steps to ensure the resident environment was free of accident hazards, as required by regulations.
Deficiencies in Food Safety Standards
Penalty
Summary
The facility was found to have deficiencies in food service safety standards during a survey. Specifically, two staff members in the main kitchen, a Dietary Aide and a Cook, were observed with full facial hair and were not wearing beard restraints while handling food. This is a violation of the Rhode Island Food Code 2018 Edition, which requires food employees to wear hair and beard restraints to prevent hair from contacting exposed food. The Food Service Director acknowledged this oversight during an interview with the surveyor. Additionally, an ice machine on the first floor was observed to lack an air gap, which is a requirement under the Rhode Island Food Code 2018 Edition. The code mandates that an air gap between the water supply inlet and the flood level rim of the plumbing fixture must be at least twice the diameter of the water supply inlet and not less than 25 millimeters. The Director of Maintenance and the Food Service Director confirmed the absence of the required air gap during the surveyor's observation.
Deficiency in Call Light Communication System
Penalty
Summary
The facility was found to be inadequately equipped to allow residents to call for staff assistance through a communication system that relays the call directly to a staff member or a centralized staff work area. During a resident council task, multiple residents complained about long wait times for their call lights to be answered, attributing this to the staff no longer carrying walkie talkies. Surveyor observations across all units revealed that not all resident rooms' call lights were visible from the nurse's station, and the call lights did not relay calls directly to staff members or a centralized staff work area. Interviews with various staff members, including LPNs and NAs, confirmed that the call lights previously communicated with walkie talkies carried by Nursing Assistants, but these devices were no longer in use. Staff members acknowledged that the only indication of an engaged call light was the light above the resident's door, with no centralized alert system in place. The facility's Administrator also confirmed that the call lights did not communicate directly to staff or a centralized location, contributing to the deficiency in responding promptly to residents' needs.
Deficiencies in Adhering to Physician Orders and Care Plans
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for several residents. For Resident ID #77, who was readmitted with MRSA and type 2 diabetes, the facility did not adhere to the physician's order to change the wound dressing on the resident's left foot twice daily. The dressing was not changed on multiple occasions, and during an observation, the dressing was found with dried drainage, indicating neglect in following the prescribed treatment plan. Resident ID #33, in a persistent vegetative state, had a stage 4 pressure ulcer on the coccyx. The physician's order required a 5-minute soak with vashe, but during an observation, the soak was only performed for approximately 2 minutes. Additionally, the resident was not wearing hand splints as ordered, with multiple observations confirming their absence. Staff interviews revealed a lack of awareness and adherence to the care plan. For Resident ID #20, the use of a Freestyle Libre sensor for glucose monitoring was not documented in the physician's orders or care plan, indicating a lack of oversight in managing the resident's diabetes care. Furthermore, Resident ID #103 had a hot pack applied for back pain, but it was left on for two hours instead of the prescribed 15 minutes. Staff interviews confirmed a lack of knowledge regarding the correct duration for the hot pack application.
Failure to Implement Contact Precautions for Residents with MDROs
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding the implementation of contact precautions for residents with Multidrug Resistant Organisms (MDROs). Four residents, identified as having conditions such as Methicillin Resistant Staphylococcus Aureus (MRSA) and Extended-spectrum beta-lactamases (ESBL), were observed to be on contact precautions. However, staff members repeatedly entered these residents' rooms without adhering to the required precautions of wearing gowns and gloves, as indicated by the signage posted outside the rooms. For Resident ID #77, who had MRSA in wounds on their feet, a Nursing Assistant entered the room without the necessary protective equipment. Similarly, for Resident ID #153, who had MRSA in their urine, a Licensed Practical Nurse also failed to wear a gown and gloves upon room entry. These actions were contrary to the facility's policy and the posted instructions, which were acknowledged by the staff during interviews. Resident ID #330, diagnosed with ESBL, had multiple staff members, including maintenance staff, an occupational therapist, and an activity aide, enter their room without the required protective gear. Additionally, Resident ID #332, with MRSA in their nares, had a Certified Occupational Therapy Assistant enter their room without a gown or gloves. Interviews with the staff revealed misunderstandings about the necessity of wearing protective equipment upon room entry, despite clear signage and facility expectations. The Infection Preventionist, Director of Nursing Services, and the Administrator all confirmed that staff should adhere to these precautions.
Failure to Provide Assistive Devices for Safe Smoking
Penalty
Summary
The facility failed to ensure that a resident was provided with assistive devices to prevent accidents related to smoking. The resident, who was admitted in April 2023 with diagnoses including traumatic brain injury, schizoaffective disorder, and epilepsy, was observed smoking without a smoking apron, contrary to the facility's policy and the resident's care plan. The care plan indicated that the resident could smoke safely with a smoking apron, but it did not specify when the apron should be applied. During the observation, ashes from the resident's cigarette were seen landing on their pajama pants. Staff interviews revealed a lack of awareness regarding the specific circumstances under which the resident should wear a smoking apron. The Registered Nurse present during the observation acknowledged the absence of the apron and the falling ashes. The Assistant Director of Nursing confirmed that the resident's smoking assessment required the use of a smoking apron. The Director of Nursing Services also acknowledged the requirement but noted that the resident sometimes refused to wear the apron, although no documentation of such refusals was available.
Significant Medication Errors with Coumadin Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, particularly concerning the administration of Coumadin, an anticoagulant medication. For Resident ID #1, despite a physician's order to hold Coumadin due to an elevated INR, the medication was administered, leading to a critically high INR and an unwitnessed fall. The Director of Nursing Services acknowledged the failure to transcribe the order to hold the medication, and the Registered Nurse Practitioner was unaware of the administration error. Resident ID #4 experienced a missed dose of Coumadin due to a transcription error, which resulted in the medication not being administered as scheduled. Additionally, the INR order was not transcribed, leading to a delay in monitoring the resident's blood clotting levels. The Licensed Practical Nurse could not explain the omission, indicating a lapse in the facility's medication administration process. Other residents, including Resident IDs #5, #6, #7, #8, and #9, also experienced medication errors due to transcription mistakes and missed doses. These errors included incorrect start and stop dates for Coumadin administration, leading to missed doses and incorrect dosing. The facility's staff, including Registered Nurse Practitioners and Licensed Practical Nurses, acknowledged the transcription errors and the resulting significant medication errors during surveyor interviews.
Failure to Provide Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide necessary treatment and services to promote wound healing and prevent new pressure ulcers from developing for a resident with existing pressure ulcers. The resident was admitted with a Stage 2 pressure injury to the buttocks and later developed a Stage 1 pressure injury on the right heel. Despite the identification of the new pressure injury by a Licensed Practical Nurse (LPN), there was no evidence that the provider was notified or that a treatment plan was implemented for the new injury. The weekly skin checks documented the presence of the pressure injury on the resident's right heel, but there was no further description or treatment order documented. The Director of Nursing Services was unaware of the pressure injury and could not provide evidence of any treatment being implemented when the injury was first identified. This lack of action and communication led to the deficiency in providing appropriate pressure ulcer care and prevention measures for the resident.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care to a resident who required oxygen therapy, as evidenced by the incorrect transcription of a physician's order. The resident, who had a history of traumatic brain injury and anxiety, was diagnosed with Influenza A and required oxygen therapy to maintain oxygen saturation levels above 91%. However, the order for oxygen therapy was incorrectly transcribed to start and end on the same day, leading to a lack of active orders for continued oxygen therapy. On the day following the incorrect transcription, the resident experienced a fall and was found in distress with an oxygen saturation level of 86%. Despite being placed back on oxygen and receiving a nebulizer treatment, the resident's oxygen saturation only increased to 90%. The resident refused transfer to a hospital after EMS was called. Throughout the day, the resident's oxygen saturation levels fluctuated, and it was unclear whether the resident was consistently receiving oxygen therapy as required. The situation escalated when the resident's oxygen saturation dropped to 80% on 2 liters of oxygen, leading to a call to 911 and the resident's transfer to an acute care hospital. The resident was diagnosed with acute respiratory failure and later with pyothorax, requiring intubation and transfer to a trauma hospital. Interviews with staff revealed a lack of awareness regarding the resident's oxygen needs and the incorrect transcription of the oxygen order, contributing to the deficiency in care.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, leading to a deficiency in safeguarding resident-identifiable information. The resident, who was admitted in October 2023 with diagnoses including traumatic brain injury and anxiety, was inaccurately documented as having an open area on the coccyx during a weekly skin assessment. This error was acknowledged by the Registered Nurse, Staff E, who completed the assessment and admitted to documenting the open area in error. The Director of Nursing Services confirmed the inaccuracy but was unable to explain why the resident's medical record was incorrect. This deficiency was identified during a surveyor interview and record review, highlighting a lapse in maintaining medical records in accordance with accepted professional standards.
Failure to Monitor and Report Resident's Weight
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for a resident with diagnoses including congestive heart failure, type 2 diabetes mellitus, and major depressive disorder. The resident had a physician's order for daily weights with specific instructions to report significant weight changes. However, the resident's weight was not obtained on 8 out of 18 opportunities, and it was documented as refused on 5 occasions. The resident denied refusing to be weighed, and the primary nurse admitted to documenting refusals when the resident was asleep. Additionally, a significant weight gain of 9.2 pounds over four days was not reported to the provider, and no interventions were implemented for this weight gain. Interviews with the resident, nursing staff, and the Director of Nursing Services revealed that the nurses did not follow the physician's order, and the provider was not notified of the weight gain or missed weights. The Nurse Practitioner was unaware of the resident's non-compliance and the significant weight gain, indicating a communication breakdown within the facility. The Director of Nursing Services acknowledged that the nurses should have followed the physician's order and reported the weight gain to the provider.
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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